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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">lentigo maligna</span> &#40;LM&#41; was first described by Hutchinson in 1890&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is used to describe melanoma in situ that develops on chronically sun-exposed skin in elderly individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Approximately 86&#37; of all cases occur in the head and neck region&#44; which is by far the most common site affected&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">lentigo maligna melanoma</span> &#40;LMM&#41; is used to describe the invasive form of LM&#46; In Spain LMM accounts for 8&#37; of all invasive melanomas excised annually&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The majority of studies of LM to date have analyzed lesions on the head and neck&#44; with few series analyzing extrafacial locations&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We undertook a descriptive study of the clinical&#44; dermoscopic&#44; and histologic characteristics of extrafacial LM&#47;LMM diagnosed at 2 Spanish hospitals&#58; Hospital General Universitario de Valencia &#40;HGU&#41; and Hospital de Manacor &#40;HMAN&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main inclusion criterion was that the specimens had been examined by the same dermatopathologist&#46; At the time of the study&#44; the database at HGU contained information on 296 LM and LMM cases diagnosed since 1990&#44; and 44 of these were extrafacial&#46; Following histologic confirmation of extrafacial LM and LMM&#44; only those tumors with a clinical and a dermoscopic image of the lesion were selected for inclusion in the study &#40;n&#160;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#160;11&#41;&#46; At HDM&#44; only lesions diagnosed in 2014 and 2015 and that met the study criteria were included&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For all specimens&#44; sections measuring 4&#160;&#956;m were cut and stained with hematoxylin and eosin&#46; LM was defined as a melanoma in situ formed by a proliferation of atypical&#44; predominantly single&#44; melanocytes along the basal layer of the epidermis and adnexal structures with poorly defined borders&#44; accompanied by epidermal atrophy and solar elastosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> These melanocytes occasionally form small nests at the dermal-epidermal junction and are typically surrounded by a light halo caused by a retraction artifact&#46; There may also be multinucleated giant cells in the epidermis&#44; and upward &#40;pagetoid&#41; spread of melanocytes is not a prominent finding&#46; Melanophages are observed in the papillary dermis&#46; LMM was defined using the same criteria as above in addition to dermal invasion by neoplastic cells&#46; Breslow thickness was measured in all invasive lesions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Superficial spreading melanoma &#40;SSM&#41; differs from LM in that it does not generally show signs of significant sun damage&#44; the epidermis is acanthotic&#44; and there are solitary or nested epithelioid cells with abundant cytoplasm and clumps of melanin distributed throughout the epidermis&#46; Mitotic activity is also observed&#44; together with pagetoid spread &#40;a common finding&#41; and regression phenomena with an accompanying inflammatory infiltrate&#46; The above criteria were used to differentiate between LM&#47;LMM and SSM&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">We studied 8 women and 6 men with a mean age of 75 years &#40;median&#44; 78 years&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Eight lesions were located on the upper limbs&#44; 3 on the trunk &#40;the scapula&#41;&#44; and 3 on the lower limbs&#46; The mean maximum diameter was 15&#46;78<span class="elsevierStyleHsp" style=""></span>mm&#46; Clinically&#44; most of the lesions were described as slow-growing&#44; asymmetric macules with poorly defined borders&#44; heterogeneous pigmentation&#44; and colors ranging from light to dark brown with white-grayish areas of regression&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Dermoscopic examination of the lesions showed characteristic findings of both LM and SSM&#46; We searched for the presence of dermoscopic features described for facial LM&#44; namely rhomboidal structures &#40;present in 9&#47;14 lesions&#41;&#44; annular-granular pigmentation &#40;5&#47;14&#41;&#44; asymmetric perifollicular pigmentation &#40;3&#47;14&#41;&#44; obliteration of follicular openings &#40;3&#47;14&#41;&#44; increased vascular network &#40;2&#47;14&#41;&#44; red rhomboidal structures &#40;2&#47;14&#41;&#44; and isobar structures&#44; and darkening at dermoscopic examination &#40;0&#47;14&#41;&#46; We also evaluated dermoscopic signs associated with SSM&#44; i&#46;e&#46;&#44; regression &#40;12&#47;14&#41;&#44; an atypical network &#40;10&#47;14&#41;&#44; irregular dots or globules &#40;10&#47;14&#41;&#44; pseudopods &#40;4&#47;14&#41;&#44; a blue-white veil &#40;4&#47;14&#41;&#44; and black lamella &#40;0&#47;14&#41;&#46; These findings are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">We recorded 17 histologic features&#44; shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Mean Breslow thickness for the 5 invasive lesions was 0&#46;26<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">LM has low malignant potential and is characterized by slow progression to the invasive form LMM&#46; Invasive lesions have a similar prognosis to SSM&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical and dermoscopic appearance of lesions are determined by the characteristics of the sun-damaged skin in which they arise &#40;epidermal atrophy and effacement of rete ridges&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Clinically&#44; LM presents as a slow-growing pigmented macule in chronically sun-exposed areas of the skin &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; It is characterized by asymmetric pigmentation and morphology&#44; and has poorly defined borders&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Extrafacial LM was first described by Hutchinson&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> but these lesions account for less than 20&#37; of all LM cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Dermoscopic features of facial LM have been extensively described and include dark and red rhomboidal structures&#44; asymmetric perifollicular pigmentation&#44; obliteration of follicular openings&#44; annular-granular pigmentation&#44; isobar structures&#44; and an increased vascular network&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#8211;9</span></a> These features are largely determined by the structural characteristics of the skin on the face &#40;effaced rete ridges and prominent adnexal structures&#41;&#46; These distinctive anatomic characteristics must therefore be borne in mind when interpreting lentigo-like dermoscopic findings in locations other than the face &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In the largest series of LM&#47;LMM published to date&#44; Cox et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> described a prevalence of 17&#46;5&#37; for extrafacial lesions&#59; most of the patients were women &#40;49 vs 22 men&#41; and the mean age was 63 years&#44; which is somewhat lower than that in our series &#40;75 years&#41;&#46; Similarly to in our patients&#44; the lesions were located predominantly on the trunk &#40;68&#37;&#41; in men and on the limbs &#40;80&#37;&#41; in women&#46; Cox et al&#46; did not report any clinical or dermoscopic features&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Some years later&#44; Lau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> described the dermoscopic findings of LM on the upper limbs of 3 women&#46; They highlighted the presence of structures associated with both SSM &#40;network&#44; dots&#47;globules&#44; pseudopods&#41; and LM &#40;rhomboidal structures and perifollicular pigmentation&#41; and concluded that these 2 patterns coexist and that the presence of rhomboidal structures and asymmetric perifollicular pigmentation would point to a diagnosis of LM&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2014&#44; Keir<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> reported on a series of 20 patients with extrafacial LM in which 90&#37; of lesions had a poorly defined border and a lentigo-like pattern&#44; defined as any combination of fine reticular lines&#44; fingerprint-like structures&#44; and light brown areas&#46; Ten &#40;71&#37;&#41; of the 14 lesions in our series had these features&#44; supporting their potential diagnostic value&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The histologic differences between LMM and SSM were described by Clark et al&#46; in 1969&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> For SSM&#44; the authors described nests of cells with a more monomorphous appearance than in LMM and a greater pagetoid distribution of melanocytes&#46; For LMM&#44; they described a predominance of epidermal atrophy&#44; with proliferation of single melanocytes and a greater degree of cellular pleomorphism&#44; in addition to involvement of adnexal structures and less frequent melanocytic nest formation&#46; In our series&#44; isolated nests were observed in 13 of the 14 cases&#44; while focal pagetoid spread of melanocytes was observed in 11 cases&#46; Cytologically&#44; our findings were consistent with the descriptions by Clark et al&#46;&#44; with marked cellular pleomorphism and more epithelioid than spindle cells&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Histologic findings did not differ to those described for facial LM&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">LM progresses very slowly and may therefore be present for years&#46; This slow-growing melanoma&#44; however&#44; has excellent prognosis&#46; Most lesions are in situ and if they acquire invasive potential&#44; they generally have a low Breslow thickness&#44; although with time they can reach the same depth as any melanoma&#46; Dermoscopic features include a mix of patterns seen in facial LM and SSM&#44; although typical features of SSM are dominant in larger lesions&#46; The literature to date contains few reports of extrafacial LM&#47;LMM&#44; and more studies are needed to identify specific criteria to improve the accuracy of clinical diagnosis&#44; as based on the data available so far&#44; extrafacial LM has overlapping dermoscopic features with SSM&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital&#39;s protocol on the publication of data concerning patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna is the most common form of in situ melanoma&#46; It is most often found on the head and neck&#44; and its clinical and dermoscopic features in this location have been extensively described in the literature&#46; We present a series of 14 patients diagnosed with extrafacial lentigo maligna and lentigo maligna melanoma at Hospital General de Valencia and Hospital de Manacor in Spain&#44; and describe the clinical&#44; dermoscopic&#44; and histologic features observed&#46; Most of the melanomas were located on the upper limbs&#59; the next most common locations were the trunk and the lower limbs&#46; The dermoscopic patterns were consistent with facial lentigo maligna and superficial spreading melanoma&#46; Extrafacial lentigo maligna is uncommon&#46; It has similar clinical and histologic features to facial lentigo&#44; but dermoscopy may show a mix of patterns typically seen in lentigo maligna and superficial spreading melanoma&#46; This difference in dermoscopic features is essentially due to anatomical differences between skin on the face and on other parts of the body&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El lentigo maligno es actualmente la variante m&#225;s frecuente de melanoma <span class="elsevierStyleItalic">in situ</span>&#46; Se localiza principalmente en la cabeza y el cuello&#44; donde sus caracter&#237;sticas cl&#237;nicas y dermatosc&#243;picas est&#225;n descritas ampliamente en la literatura&#46; Presentamos una serie de 14 pacientes diagnosticados de lentigo maligno y lentigo maligno melanoma extrafacial en el Hospital General de Valencia y Hospital de Manacor&#44; describiendo los hallazgos cl&#237;nicos&#44; dermatosc&#243;picos e histol&#243;gicos de los mismos&#46; La localizaci&#243;n m&#225;s frecuentemente encontrada fue las extremidades superiores&#44; seguida del tronco y las extremidades inferiores&#46; En la dermatoscopia se hallaron patrones compatibles con lentigo maligno facial y melanoma de extensi&#243;n superficial&#46; La localizaci&#243;n extracef&#225;lica de los lentigos malignos es poco frecuente&#46; Cl&#237;nica e histol&#243;gicamente muestra caracter&#237;sticas semejantes al de localizaci&#243;n facial&#44; aunque en la dermatoscopia podemos encontrar una mezcla de patrones de lentigo maligno y melanoma de extensi&#243;n superficial&#44; debido principalmente a las diferencias entre las caracter&#237;sticas anat&#243;micas de la piel facial y la extrafacial&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez-Lebor&#225;ns L&#44; Garc&#237;as-Ladaria J&#44; Oliver-Mart&#237;nez V&#44; Miquel VA&#46; Lentigo maligno extrafacial&#46; Serie de 14 casos y revisi&#243;n de la literatura&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e57&#8211;e63&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient &#35;2&#58; An 88-year-old man with a pigmented macule present on his hand for years&#46; A&#44; Pigmented macule with asymmetric morphology and pigmentation&#46; B&#44; Dermoscopic image showing annular-granular pigmentation at one of the borders&#44; together with rhomboidal structures and areas of regression&#46; C&#44; Histologic image of excised lesion showing proliferation of single melanocytes surrounded by a light halo in sun-damaged skin &#40;marked solar elastosis&#41; in addition to epidermal atrophy &#40;hematoxylin-eosin&#44; original magnification &#215;20&#41;&#46; D&#44; A higher-magnification view shows a proliferation of epithelioid cells with a pagetoid distribution and subepidermal fibrosis &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient &#35;4&#58; A 63-year-old man with a pigmented lesion on the scapula&#46; A&#44; A 13-mm pigmented macule on the left scapula&#46; B&#44; Dermoscopic image showing asymmetric follicular pigmentation&#44; rhomboidal structures&#44; and some obliterated follicular openings&#46; Note also the features typically associated with superficial spreading melanoma&#44; such as the atypical network&#44; regression areas&#44; and a blue-white veil&#46; C&#44; Proliferation of solitary and small nests of epithelioid melanocytes in the epidermis&#44; with an accompanying inflammatory infiltrate&#44; involvement of the adnexal epithelium&#44; and solar elastosis &#40;hematoxylin-eosin&#44; original magnification &#215;100&#41;&#46; D&#44; A higher-magnification view shows melanophages in the papillary dermis &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; Max Diam&#44; maximum diameter&#59; HGV&#58; Hospital General Universitario de Valencia&#59; HMAN&#44; Hospital de Manacor&#59; Tis&#44; melanoma in situ&#46;</p>"
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e-Case Report
Extrafacial Lentigo Maligna: A Report on 14 Cases and a Review of the Literature
Lentigo maligno extrafacial. Serie de 14 casos y revisión de la literatura
L. Martínez-Leboránsa,
Autor para correspondencia
lorenamarleb@gmail.com

Corresponding author.
, J. Garcías-Ladariab, V. Oliver-Martíneza, V. Alegre de Miquela,c
a Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, Spain
b Servicio de Dermatología, Hospital Manacor, Manacor, Mallorca, Spain
c Universidad de Valencia, Valencia, Spain
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient &#35;4&#58; A 63-year-old man with a pigmented lesion on the scapula&#46; A&#44; A 13-mm pigmented macule on the left scapula&#46; B&#44; Dermoscopic image showing asymmetric follicular pigmentation&#44; rhomboidal structures&#44; and some obliterated follicular openings&#46; Note also the features typically associated with superficial spreading melanoma&#44; such as the atypical network&#44; regression areas&#44; and a blue-white veil&#46; C&#44; Proliferation of solitary and small nests of epithelioid melanocytes in the epidermis&#44; with an accompanying inflammatory infiltrate&#44; involvement of the adnexal epithelium&#44; and solar elastosis &#40;hematoxylin-eosin&#44; original magnification &#215;100&#41;&#46; D&#44; A higher-magnification view shows melanophages in the papillary dermis &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">lentigo maligna</span> &#40;LM&#41; was first described by Hutchinson in 1890&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is used to describe melanoma in situ that develops on chronically sun-exposed skin in elderly individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Approximately 86&#37; of all cases occur in the head and neck region&#44; which is by far the most common site affected&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">lentigo maligna melanoma</span> &#40;LMM&#41; is used to describe the invasive form of LM&#46; In Spain LMM accounts for 8&#37; of all invasive melanomas excised annually&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The majority of studies of LM to date have analyzed lesions on the head and neck&#44; with few series analyzing extrafacial locations&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We undertook a descriptive study of the clinical&#44; dermoscopic&#44; and histologic characteristics of extrafacial LM&#47;LMM diagnosed at 2 Spanish hospitals&#58; Hospital General Universitario de Valencia &#40;HGU&#41; and Hospital de Manacor &#40;HMAN&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main inclusion criterion was that the specimens had been examined by the same dermatopathologist&#46; At the time of the study&#44; the database at HGU contained information on 296 LM and LMM cases diagnosed since 1990&#44; and 44 of these were extrafacial&#46; Following histologic confirmation of extrafacial LM and LMM&#44; only those tumors with a clinical and a dermoscopic image of the lesion were selected for inclusion in the study &#40;n&#160;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#160;11&#41;&#46; At HDM&#44; only lesions diagnosed in 2014 and 2015 and that met the study criteria were included&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For all specimens&#44; sections measuring 4&#160;&#956;m were cut and stained with hematoxylin and eosin&#46; LM was defined as a melanoma in situ formed by a proliferation of atypical&#44; predominantly single&#44; melanocytes along the basal layer of the epidermis and adnexal structures with poorly defined borders&#44; accompanied by epidermal atrophy and solar elastosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> These melanocytes occasionally form small nests at the dermal-epidermal junction and are typically surrounded by a light halo caused by a retraction artifact&#46; There may also be multinucleated giant cells in the epidermis&#44; and upward &#40;pagetoid&#41; spread of melanocytes is not a prominent finding&#46; Melanophages are observed in the papillary dermis&#46; LMM was defined using the same criteria as above in addition to dermal invasion by neoplastic cells&#46; Breslow thickness was measured in all invasive lesions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Superficial spreading melanoma &#40;SSM&#41; differs from LM in that it does not generally show signs of significant sun damage&#44; the epidermis is acanthotic&#44; and there are solitary or nested epithelioid cells with abundant cytoplasm and clumps of melanin distributed throughout the epidermis&#46; Mitotic activity is also observed&#44; together with pagetoid spread &#40;a common finding&#41; and regression phenomena with an accompanying inflammatory infiltrate&#46; The above criteria were used to differentiate between LM&#47;LMM and SSM&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">We studied 8 women and 6 men with a mean age of 75 years &#40;median&#44; 78 years&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Eight lesions were located on the upper limbs&#44; 3 on the trunk &#40;the scapula&#41;&#44; and 3 on the lower limbs&#46; The mean maximum diameter was 15&#46;78<span class="elsevierStyleHsp" style=""></span>mm&#46; Clinically&#44; most of the lesions were described as slow-growing&#44; asymmetric macules with poorly defined borders&#44; heterogeneous pigmentation&#44; and colors ranging from light to dark brown with white-grayish areas of regression&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Dermoscopic examination of the lesions showed characteristic findings of both LM and SSM&#46; We searched for the presence of dermoscopic features described for facial LM&#44; namely rhomboidal structures &#40;present in 9&#47;14 lesions&#41;&#44; annular-granular pigmentation &#40;5&#47;14&#41;&#44; asymmetric perifollicular pigmentation &#40;3&#47;14&#41;&#44; obliteration of follicular openings &#40;3&#47;14&#41;&#44; increased vascular network &#40;2&#47;14&#41;&#44; red rhomboidal structures &#40;2&#47;14&#41;&#44; and isobar structures&#44; and darkening at dermoscopic examination &#40;0&#47;14&#41;&#46; We also evaluated dermoscopic signs associated with SSM&#44; i&#46;e&#46;&#44; regression &#40;12&#47;14&#41;&#44; an atypical network &#40;10&#47;14&#41;&#44; irregular dots or globules &#40;10&#47;14&#41;&#44; pseudopods &#40;4&#47;14&#41;&#44; a blue-white veil &#40;4&#47;14&#41;&#44; and black lamella &#40;0&#47;14&#41;&#46; These findings are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">We recorded 17 histologic features&#44; shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Mean Breslow thickness for the 5 invasive lesions was 0&#46;26<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">LM has low malignant potential and is characterized by slow progression to the invasive form LMM&#46; Invasive lesions have a similar prognosis to SSM&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical and dermoscopic appearance of lesions are determined by the characteristics of the sun-damaged skin in which they arise &#40;epidermal atrophy and effacement of rete ridges&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Clinically&#44; LM presents as a slow-growing pigmented macule in chronically sun-exposed areas of the skin &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; It is characterized by asymmetric pigmentation and morphology&#44; and has poorly defined borders&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Extrafacial LM was first described by Hutchinson&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> but these lesions account for less than 20&#37; of all LM cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Dermoscopic features of facial LM have been extensively described and include dark and red rhomboidal structures&#44; asymmetric perifollicular pigmentation&#44; obliteration of follicular openings&#44; annular-granular pigmentation&#44; isobar structures&#44; and an increased vascular network&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#8211;9</span></a> These features are largely determined by the structural characteristics of the skin on the face &#40;effaced rete ridges and prominent adnexal structures&#41;&#46; These distinctive anatomic characteristics must therefore be borne in mind when interpreting lentigo-like dermoscopic findings in locations other than the face &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In the largest series of LM&#47;LMM published to date&#44; Cox et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> described a prevalence of 17&#46;5&#37; for extrafacial lesions&#59; most of the patients were women &#40;49 vs 22 men&#41; and the mean age was 63 years&#44; which is somewhat lower than that in our series &#40;75 years&#41;&#46; Similarly to in our patients&#44; the lesions were located predominantly on the trunk &#40;68&#37;&#41; in men and on the limbs &#40;80&#37;&#41; in women&#46; Cox et al&#46; did not report any clinical or dermoscopic features&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Some years later&#44; Lau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> described the dermoscopic findings of LM on the upper limbs of 3 women&#46; They highlighted the presence of structures associated with both SSM &#40;network&#44; dots&#47;globules&#44; pseudopods&#41; and LM &#40;rhomboidal structures and perifollicular pigmentation&#41; and concluded that these 2 patterns coexist and that the presence of rhomboidal structures and asymmetric perifollicular pigmentation would point to a diagnosis of LM&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2014&#44; Keir<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> reported on a series of 20 patients with extrafacial LM in which 90&#37; of lesions had a poorly defined border and a lentigo-like pattern&#44; defined as any combination of fine reticular lines&#44; fingerprint-like structures&#44; and light brown areas&#46; Ten &#40;71&#37;&#41; of the 14 lesions in our series had these features&#44; supporting their potential diagnostic value&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The histologic differences between LMM and SSM were described by Clark et al&#46; in 1969&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> For SSM&#44; the authors described nests of cells with a more monomorphous appearance than in LMM and a greater pagetoid distribution of melanocytes&#46; For LMM&#44; they described a predominance of epidermal atrophy&#44; with proliferation of single melanocytes and a greater degree of cellular pleomorphism&#44; in addition to involvement of adnexal structures and less frequent melanocytic nest formation&#46; In our series&#44; isolated nests were observed in 13 of the 14 cases&#44; while focal pagetoid spread of melanocytes was observed in 11 cases&#46; Cytologically&#44; our findings were consistent with the descriptions by Clark et al&#46;&#44; with marked cellular pleomorphism and more epithelioid than spindle cells&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Histologic findings did not differ to those described for facial LM&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">LM progresses very slowly and may therefore be present for years&#46; This slow-growing melanoma&#44; however&#44; has excellent prognosis&#46; Most lesions are in situ and if they acquire invasive potential&#44; they generally have a low Breslow thickness&#44; although with time they can reach the same depth as any melanoma&#46; Dermoscopic features include a mix of patterns seen in facial LM and SSM&#44; although typical features of SSM are dominant in larger lesions&#46; The literature to date contains few reports of extrafacial LM&#47;LMM&#44; and more studies are needed to identify specific criteria to improve the accuracy of clinical diagnosis&#44; as based on the data available so far&#44; extrafacial LM has overlapping dermoscopic features with SSM&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital&#39;s protocol on the publication of data concerning patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna is the most common form of in situ melanoma&#46; It is most often found on the head and neck&#44; and its clinical and dermoscopic features in this location have been extensively described in the literature&#46; We present a series of 14 patients diagnosed with extrafacial lentigo maligna and lentigo maligna melanoma at Hospital General de Valencia and Hospital de Manacor in Spain&#44; and describe the clinical&#44; dermoscopic&#44; and histologic features observed&#46; Most of the melanomas were located on the upper limbs&#59; the next most common locations were the trunk and the lower limbs&#46; The dermoscopic patterns were consistent with facial lentigo maligna and superficial spreading melanoma&#46; Extrafacial lentigo maligna is uncommon&#46; It has similar clinical and histologic features to facial lentigo&#44; but dermoscopy may show a mix of patterns typically seen in lentigo maligna and superficial spreading melanoma&#46; This difference in dermoscopic features is essentially due to anatomical differences between skin on the face and on other parts of the body&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El lentigo maligno es actualmente la variante m&#225;s frecuente de melanoma <span class="elsevierStyleItalic">in situ</span>&#46; Se localiza principalmente en la cabeza y el cuello&#44; donde sus caracter&#237;sticas cl&#237;nicas y dermatosc&#243;picas est&#225;n descritas ampliamente en la literatura&#46; Presentamos una serie de 14 pacientes diagnosticados de lentigo maligno y lentigo maligno melanoma extrafacial en el Hospital General de Valencia y Hospital de Manacor&#44; describiendo los hallazgos cl&#237;nicos&#44; dermatosc&#243;picos e histol&#243;gicos de los mismos&#46; La localizaci&#243;n m&#225;s frecuentemente encontrada fue las extremidades superiores&#44; seguida del tronco y las extremidades inferiores&#46; En la dermatoscopia se hallaron patrones compatibles con lentigo maligno facial y melanoma de extensi&#243;n superficial&#46; La localizaci&#243;n extracef&#225;lica de los lentigos malignos es poco frecuente&#46; Cl&#237;nica e histol&#243;gicamente muestra caracter&#237;sticas semejantes al de localizaci&#243;n facial&#44; aunque en la dermatoscopia podemos encontrar una mezcla de patrones de lentigo maligno y melanoma de extensi&#243;n superficial&#44; debido principalmente a las diferencias entre las caracter&#237;sticas anat&#243;micas de la piel facial y la extrafacial&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez-Lebor&#225;ns L&#44; Garc&#237;as-Ladaria J&#44; Oliver-Mart&#237;nez V&#44; Miquel VA&#46; Lentigo maligno extrafacial&#46; Serie de 14 casos y revisi&#243;n de la literatura&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e57&#8211;e63&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient &#35;2&#58; An 88-year-old man with a pigmented macule present on his hand for years&#46; A&#44; Pigmented macule with asymmetric morphology and pigmentation&#46; B&#44; Dermoscopic image showing annular-granular pigmentation at one of the borders&#44; together with rhomboidal structures and areas of regression&#46; C&#44; Histologic image of excised lesion showing proliferation of single melanocytes surrounded by a light halo in sun-damaged skin &#40;marked solar elastosis&#41; in addition to epidermal atrophy &#40;hematoxylin-eosin&#44; original magnification &#215;20&#41;&#46; D&#44; A higher-magnification view shows a proliferation of epithelioid cells with a pagetoid distribution and subepidermal fibrosis &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient &#35;4&#58; A 63-year-old man with a pigmented lesion on the scapula&#46; A&#44; A 13-mm pigmented macule on the left scapula&#46; B&#44; Dermoscopic image showing asymmetric follicular pigmentation&#44; rhomboidal structures&#44; and some obliterated follicular openings&#46; Note also the features typically associated with superficial spreading melanoma&#44; such as the atypical network&#44; regression areas&#44; and a blue-white veil&#46; C&#44; Proliferation of solitary and small nests of epithelioid melanocytes in the epidermis&#44; with an accompanying inflammatory infiltrate&#44; involvement of the adnexal epithelium&#44; and solar elastosis &#40;hematoxylin-eosin&#44; original magnification &#215;100&#41;&#46; D&#44; A higher-magnification view shows melanophages in the papillary dermis &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; Max Diam&#44; maximum diameter&#59; HGV&#58; Hospital General Universitario de Valencia&#59; HMAN&#44; Hospital de Manacor&#59; Tis&#44; melanoma in situ&#46;</p>"
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Información del artículo
ISSN: 15782190
Idioma original: Inglés
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