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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">Dermoscopic island was described in 2010 by Borsari and coworkers<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> as a well-defined area within a melanocytic lesion&#44; with a different dermoscopic pattern from the rest of the lesion&#46; It can be solitary or multiple&#44; can be located peripherally or centrally &#40;in some cases occupying almost the entire lesion&#41;&#44; and usually lends the lesion an asymmetric appearance&#46; It is important to differentiate between dermoscopic island and eccentric hyperpigmentation&#44; which is the asymmetric distribution of pigment without structural changes&#46; Reflectance confocal microscopy &#40;RCM&#41; has been proposed as a useful tool to distinguish between benign and malignant lesions with dermoscopic island&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was an 83-year-old man with no personal or familial history of melanoma who attended our clinic for examination of actinic keratosis&#46; Physical examination revealed a light brown nevus of 4<span class="elsevierStyleHsp" style=""></span>mm in the lumbar region with asymmetry and a hyperpigmented area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; A homogenous reticular pattern and an area of eccentric hyperpigmentation with a distinct&#44; atypical reticular pattern were observed on dermoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Two distinct patterns were evident in panoramic images obtained by RCM&#46; Enlargement of the hyperpigmented area revealed isolated atypical round cells&#44; atypical cells forming nests&#44; and papillae with poorly defined contours at the dermoepidermal junction &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Malignancy was suspected and the lesion was excised&#44; revealing a proliferation of large atypical melanocytes with prominent and hyperchromatic nucleoli in the area corresponding to the hyperpigmentation&#44; and uniform melanocytes without atypia in the rest of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; The patient was diagnosed with superficial spreading melanoma on a pre-existing nevus&#44; with a Breslow thickness of 0&#46;321<span class="elsevierStyleHsp" style=""></span>mm&#46;A 10-year-old girl with no past history of interest attended our clinic for examination of pigmented lesions&#46; She had a nevus with a hyperpigmented area on her back &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Dermoscopy of the hyperpigmented area revealed light brown globules with a homogeneous morphology and distribution&#44; in contrast to the reticular pattern of the rest of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Similarly&#44; 2 distinct patterns were observed on RCM&#46; Enlargement of the area corresponding to the globular dermoscopic pattern revealed a globular pattern consisting of dense nests without atypia at the level of the dermoepidermal junction &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#44; while the area corresponding to the reticular pattern presented a mesh-like pattern without atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46; Follow-up was recommended owing to the absence of clinical findings indicating malignancy and the absence of cellular atypia on RCM&#46; After 8 months of follow-up the lesion remained stable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">At a routine examination a 69-year-old male who had an in situ melanoma on the left thigh in 2013 reported progressive growth of a lesion on the back of the right hand&#46; The 2<span class="elsevierStyleMonospace">-</span>cm lesion had a hyperpigmented area of 6<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; Dermoscopy revealed a homogenous reticular pattern throughout most of the lesion and an atypical globular pattern corresponding to the area of eccentric hyperpigmentation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; RCM of the hyperpigmented area revealed papillae with poorly defined contours&#44; discohesive nests&#44; and atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;&#46; Malignancy was suspected and the lesion was excised&#46; The patient was diagnosed with melanoma in situ &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>D&#41; with a predominantly lentiginous pattern&#44; with single-cell pagetoid invasion and some groups of atypical cells corresponding to the hyperpigmented area&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Dermoscopic island has been identified as a predictor for the diagnosis of malignant melanoma &#40;MM&#41;&#44; especially thin melanoma and nevus-associated melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It has a positive predictive value of approximately 50&#37;&#44; which increases in lesions with an atypical dermoscopic pattern&#46; Systematic excision of all lesions with the dermoscopic island&#44; regardless of the dermoscopic pattern&#44; would therefore result in unnecessary excisions in half of all cases&#46; Two articles published in 2013<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and 2016<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> propose the use of RCM as a tool to distinguish between malignant and benign lesions with dermoscopic island&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first article<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> describes 5 different patients&#44; each with a single lesion for which a clear diagnosis based on dermoscopy alone was impossible&#46; Based on RCM analysis of the lesions&#44; 2 melanocytic nevi and 3 nevus-associated melanomas were diagnosed&#46; Subsequent excision and analysis of the lesions corroborated the RCM findings&#44; which showed a good correlation with conventional histopathology&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The second article<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> describes a study in which images of 1964 pigmented lesions were analyzed&#46; Of these&#44; 63 &#40;3&#46;2&#37;&#41; presented dermoscopic island&#46; After follow-up for 1 year&#44; 17 &#40;27&#37;&#41; of the lesions&#44; which remained stable and exhibited no cellular atypia on RCM&#44; were diagnosed as nevi&#46; The remaining 46 lesions &#40;74&#37;&#41; showed signs of atypia and were excised and analyzed&#46; Of these&#44; 19 were diagnosed as MMs in situ&#44; 8 as invasive MMs &#40;mean Breslow thickness&#44; 0&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and 19 as nevi&#46; Therefore&#44; of 63 lesions with dermoscopic island&#44; 57&#46;1&#37; were nevi and 42&#46;9&#37; were MMs&#46; Furthermore&#44; significant differences &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; in the numbers of pagetoid and atypical cells at the dermoepidermal junction facilitated discrimination between nevi and melanomas using RCM&#44; which had high sensitivity and a high negative predictive value&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">RCM is a noninvasive imaging technique whereby images of the skin are obtained for in vivo analysis&#44; and offers good cellular resolution to a depth of approximately 250<span class="elsevierStyleHsp" style=""></span>&#956;m&#46; In horizontal RCM images malignancy of melanocytic lesions is indicated by the presence of pagetoid cells in the epidermis and atypical cells in the dermoepidermal junction&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In RCM images&#44; the presence of pagetoid cells in the epidermis and atypical cells in the dermoepidermal junction is the most important criterion by which MM is distinguished from melanocytic nevus&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> Lesions with dermoscopic island are good candidates for RCM&#46; This noninvasive imaging technique increases diagnostic accuracy and&#44; given its high negative predictive value&#44; allows for safer diagnosis of nevus and avoids unnecessary excision&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We present the RCM findings in 3 lesions with dermoscopic island &#40;a nevus-associated melanoma&#44; a melanocytic nevus&#44; and a melanoma in situ&#41;&#46; In 1 lesion&#44; examination of the area corresponding to the dermoscopic island revealed a globular pattern without cellular atypia on dermoscopy&#44; and the absence of cellular or architectural atypia on RCM&#46; In the other 2 lesions both dermoscopy and RCM revealed atypia in the area of the dermoscopic island&#44; and RCM showed isolated atypical round cells&#44; atypical cells forming nests&#44; discohesive nests&#44; and papillae with poorly defined contours at the dermoepidermal junction&#46; In all 3 cases&#44; RCM facilitated the diagnosis and management of melanocytic lesions with dermoscopic island&#46; RCM is useful for the study of lesions with dermoscopic island for 2 reasons&#58; this technique provides high-resolution images of the skin&#39;s most superficial layers &#40;to the level of the reticular dermis&#41;&#59; and dermoscopic island is mainly associated with fine melanoma&#44; melanoma in situ&#44; and nevus-associated melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Larger patient series could help further demonstrate the usefulness of RCM for the evaluation of these types of lesions&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The dermoscopic island is described as a well-defined area in a melanocytic lesion&#44; with a different dermoscopic pattern from the rest of the lesion&#46; It is predictive of melanoma&#44; particularly when the pattern of the island is atypical&#46; We present the reflectance confocal microscopy &#40;RCM&#41; findings in 3 lesions with dermoscopic islands&#58; nevus-associated melanoma&#44; melanocytic nevus&#44; and in situ melanoma&#46; The nevus-associated melanoma and in situ melanoma presented cellular atypia &#40;atypical cells in isolation or forming nests&#41; and architectural distortion on RCM&#46; The nevus presented a dermoscopic island with a typical globular pattern with dense nests and no atypia on RCM&#46; Dermoscopic island is mainly associated with in situ and nevus-associated melanomas&#46; RCM offers good cellular resolution to the depth of the reticular dermis and is useful for diagnosing of melanomas presenting a dermoscopic island&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El signo de la isla se define como un &#225;rea bien delimitada en una lesi&#243;n melanoc&#237;tica&#44; con un patr&#243;n dermatosc&#243;pico diferente al resto de la lesi&#243;n&#46; Es predictor de melanoma sobre todo cuando el patr&#243;n dermatosc&#243;pico de la isla es at&#237;pico&#46; Presentamos las caracter&#237;sticas con microscopia confocal de reflectancia &#40;MCR&#41; en un melanoma sobre <span class="elsevierStyleItalic">nevus</span>&#44; un <span class="elsevierStyleItalic">nevus</span> melanoc&#237;tico y un melanoma <span class="elsevierStyleItalic">in situ</span> con signo de la isla&#46; El melanoma sobre <span class="elsevierStyleItalic">nevus</span> y el melanoma <span class="elsevierStyleItalic">in situ</span>&#44; presentaban atipia celular &#40;c&#233;lulas at&#237;picas aisladas y formando nidos&#41; y distorsi&#243;n arquitectural por MCR&#46; El <span class="elsevierStyleItalic">nevus</span> presentaba un signo de la isla con un patr&#243;n globular t&#237;pico con nidos densos sin atipia por MCR&#46; El signo de la isla se relaciona sobre todo con melanomas <span class="elsevierStyleItalic">in situ</span> y melanomas sobre <span class="elsevierStyleItalic">nevus</span>&#46; El MCR ofrece una buena resoluci&#243;n celular hasta dermis reticular&#44; siendo &#250;til en el diagn&#243;stico de los melanomas con signo de la isla&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Elosua-Gonz&#225;lez M&#44; Gamo-Villegas R&#44; Florist&#225;n-Muruz&#225;bal U&#44; Pinedo-Moraleda F&#44; L&#243;pez-Estebaranz JL&#46; Microscopia confocal de reflectancia&#58; una herramienta &#250;til para diagnosticar malignidad en lesiones melanoc&#237;ticas que presenten el signo de la isla&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;e37&#8211;e41&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; dermoscopy&#44; reflectance confocal microscopy &#40;RCM&#41;&#44; and histology findings&#46; A&#44; Light brown nevus &#40;4<span class="elsevierStyleHsp" style=""></span>mm&#41; in the lumbar region with asymmetry and a hyperpigmented area&#46; B&#44; Dermoscopic island&#58; dermoscopy reveals a homogenous reticular pattern within which lies an area of eccentric hyperpigmention with a distinct&#44; atypical reticular pattern&#46; C&#44; RCM image showing isolated atypical round cells &#40;arrows&#41;&#44; atypical cells forming nests &#40;circles&#41;&#44; and papillae with poorly defined contours &#40;asterisks&#41;&#46; D&#44; Proliferation of large atypical melanocytes with prominent&#44; hyperchromatic nucleoli corresponding to the dermoscopic island &#40;hematoxylin-eosin&#44; original magnification &#215;100&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; dermoscopy&#44; and reflectance confocal microscopy &#40;RCM&#41; findings&#46; A&#44; Nevus with hyperpigmentation on the patient&#39;s back&#46; B&#44; Dermoscopic island&#58; dermoscopy reveals an area comprised of light brown globules with a homogeneous morphology and distribution&#44; in contrast to the reticular pattern observed throughout the rest of the lesion&#46; C&#44; RCM of the area corresponding to the globular dermoscopic pattern reveals a globular pattern consisting of dense nests &#40;arrows&#41; without atypia at the level of the dermoepidermal junction&#46; D&#44; The area corresponding to the reticular pattern presents a mesh-like pattern&#44; with no atypical cells&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; dermoscopy&#44; reflectance confocal microscopy &#40;RCM&#41;&#44; and histology findings&#46; A&#44; Lesion &#40;2<span class="elsevierStyleHsp" style=""></span>cm&#41; on the back of the right hand with a 6-<span class="elsevierStyleHsp" style=""></span>mm area of hyperpigmentation&#46; B&#44; Dermoscopy reveals a homogenous reticular pattern throughout most of the lesion&#44; and an atypical globular pattern corresponding to the area of eccentric hyperpigmentation&#46; C&#44; RCM of the area corresponding to the atypical globular pattern reveals papillae with poorly defined contours &#40;asterisks&#41;&#44; discohesive nests &#40;dots&#41;&#44; and atypical cells &#40;arrows&#41;&#46; D&#44; Melanoma in situ with a predominantly lentiginous pattern&#44; with single-cell pagetoid invasion &#40;asterisks&#41; and some groups of atypical cells &#40;arrows&#41; &#40;hematoxylin-eosin&#44; original magnification &#215;100&#41;&#46;</p>"
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                            2 => "T&#46; de Almeida Silva"
                            3 => "E&#46; Moscarella"
                            4 => "A&#46; Lallas"
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                            0 => "A&#46; Scope"
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                            2 => "A&#46;L&#46; Agero"
                            3 => "A&#46;C&#46; Halpern"
                            4 => "S&#46; Gonzalez"
                            5 => "A&#46;A&#46; Marghoob"
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e- Case Report
Reflectance Confocal Microscopy: A Promising Tool to Identify Malignancy in Melanocytic Lesions Exhibiting a Dermoscopic Island
Microscopia confocal de reflectancia: una herramienta útil para diagnosticar malignidad en lesiones melanocíticas que presenten el signo de la isla
M. Elosua-Gonzáleza,
Autor para correspondencia
martagelosua@gmail.com

Corresponding author.
, R. Gamo-Villegasa, U. Floristán-Muruzábala, F. Pinedo-Moraledab, J.L. López-Estebaranza
a Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
b Servicio de Anatomía Patológica, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; dermoscopy&#44; reflectance confocal microscopy &#40;RCM&#41;&#44; and histology findings&#46; A&#44; Light brown nevus &#40;4<span class="elsevierStyleHsp" style=""></span>mm&#41; in the lumbar region with asymmetry and a hyperpigmented area&#46; B&#44; Dermoscopic island&#58; dermoscopy reveals a homogenous reticular pattern within which lies an area of eccentric hyperpigmention with a distinct&#44; atypical reticular pattern&#46; C&#44; RCM image showing isolated atypical round cells &#40;arrows&#41;&#44; atypical cells forming nests &#40;circles&#41;&#44; and papillae with poorly defined contours &#40;asterisks&#41;&#46; D&#44; Proliferation of large atypical melanocytes with prominent&#44; hyperchromatic nucleoli corresponding to the dermoscopic island &#40;hematoxylin-eosin&#44; original magnification &#215;100&#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">Dermoscopic island was described in 2010 by Borsari and coworkers<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> as a well-defined area within a melanocytic lesion&#44; with a different dermoscopic pattern from the rest of the lesion&#46; It can be solitary or multiple&#44; can be located peripherally or centrally &#40;in some cases occupying almost the entire lesion&#41;&#44; and usually lends the lesion an asymmetric appearance&#46; It is important to differentiate between dermoscopic island and eccentric hyperpigmentation&#44; which is the asymmetric distribution of pigment without structural changes&#46; Reflectance confocal microscopy &#40;RCM&#41; has been proposed as a useful tool to distinguish between benign and malignant lesions with dermoscopic island&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was an 83-year-old man with no personal or familial history of melanoma who attended our clinic for examination of actinic keratosis&#46; Physical examination revealed a light brown nevus of 4<span class="elsevierStyleHsp" style=""></span>mm in the lumbar region with asymmetry and a hyperpigmented area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; A homogenous reticular pattern and an area of eccentric hyperpigmentation with a distinct&#44; atypical reticular pattern were observed on dermoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Two distinct patterns were evident in panoramic images obtained by RCM&#46; Enlargement of the hyperpigmented area revealed isolated atypical round cells&#44; atypical cells forming nests&#44; and papillae with poorly defined contours at the dermoepidermal junction &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Malignancy was suspected and the lesion was excised&#44; revealing a proliferation of large atypical melanocytes with prominent and hyperchromatic nucleoli in the area corresponding to the hyperpigmentation&#44; and uniform melanocytes without atypia in the rest of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; The patient was diagnosed with superficial spreading melanoma on a pre-existing nevus&#44; with a Breslow thickness of 0&#46;321<span class="elsevierStyleHsp" style=""></span>mm&#46;A 10-year-old girl with no past history of interest attended our clinic for examination of pigmented lesions&#46; She had a nevus with a hyperpigmented area on her back &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Dermoscopy of the hyperpigmented area revealed light brown globules with a homogeneous morphology and distribution&#44; in contrast to the reticular pattern of the rest of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Similarly&#44; 2 distinct patterns were observed on RCM&#46; Enlargement of the area corresponding to the globular dermoscopic pattern revealed a globular pattern consisting of dense nests without atypia at the level of the dermoepidermal junction &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#44; while the area corresponding to the reticular pattern presented a mesh-like pattern without atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46; Follow-up was recommended owing to the absence of clinical findings indicating malignancy and the absence of cellular atypia on RCM&#46; After 8 months of follow-up the lesion remained stable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">At a routine examination a 69-year-old male who had an in situ melanoma on the left thigh in 2013 reported progressive growth of a lesion on the back of the right hand&#46; The 2<span class="elsevierStyleMonospace">-</span>cm lesion had a hyperpigmented area of 6<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; Dermoscopy revealed a homogenous reticular pattern throughout most of the lesion and an atypical globular pattern corresponding to the area of eccentric hyperpigmentation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; RCM of the hyperpigmented area revealed papillae with poorly defined contours&#44; discohesive nests&#44; and atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;&#46; Malignancy was suspected and the lesion was excised&#46; The patient was diagnosed with melanoma in situ &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>D&#41; with a predominantly lentiginous pattern&#44; with single-cell pagetoid invasion and some groups of atypical cells corresponding to the hyperpigmented area&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Dermoscopic island has been identified as a predictor for the diagnosis of malignant melanoma &#40;MM&#41;&#44; especially thin melanoma and nevus-associated melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It has a positive predictive value of approximately 50&#37;&#44; which increases in lesions with an atypical dermoscopic pattern&#46; Systematic excision of all lesions with the dermoscopic island&#44; regardless of the dermoscopic pattern&#44; would therefore result in unnecessary excisions in half of all cases&#46; Two articles published in 2013<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and 2016<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> propose the use of RCM as a tool to distinguish between malignant and benign lesions with dermoscopic island&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first article<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> describes 5 different patients&#44; each with a single lesion for which a clear diagnosis based on dermoscopy alone was impossible&#46; Based on RCM analysis of the lesions&#44; 2 melanocytic nevi and 3 nevus-associated melanomas were diagnosed&#46; Subsequent excision and analysis of the lesions corroborated the RCM findings&#44; which showed a good correlation with conventional histopathology&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The second article<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> describes a study in which images of 1964 pigmented lesions were analyzed&#46; Of these&#44; 63 &#40;3&#46;2&#37;&#41; presented dermoscopic island&#46; After follow-up for 1 year&#44; 17 &#40;27&#37;&#41; of the lesions&#44; which remained stable and exhibited no cellular atypia on RCM&#44; were diagnosed as nevi&#46; The remaining 46 lesions &#40;74&#37;&#41; showed signs of atypia and were excised and analyzed&#46; Of these&#44; 19 were diagnosed as MMs in situ&#44; 8 as invasive MMs &#40;mean Breslow thickness&#44; 0&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and 19 as nevi&#46; Therefore&#44; of 63 lesions with dermoscopic island&#44; 57&#46;1&#37; were nevi and 42&#46;9&#37; were MMs&#46; Furthermore&#44; significant differences &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; in the numbers of pagetoid and atypical cells at the dermoepidermal junction facilitated discrimination between nevi and melanomas using RCM&#44; which had high sensitivity and a high negative predictive value&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">RCM is a noninvasive imaging technique whereby images of the skin are obtained for in vivo analysis&#44; and offers good cellular resolution to a depth of approximately 250<span class="elsevierStyleHsp" style=""></span>&#956;m&#46; In horizontal RCM images malignancy of melanocytic lesions is indicated by the presence of pagetoid cells in the epidermis and atypical cells in the dermoepidermal junction&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In RCM images&#44; the presence of pagetoid cells in the epidermis and atypical cells in the dermoepidermal junction is the most important criterion by which MM is distinguished from melanocytic nevus&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> Lesions with dermoscopic island are good candidates for RCM&#46; This noninvasive imaging technique increases diagnostic accuracy and&#44; given its high negative predictive value&#44; allows for safer diagnosis of nevus and avoids unnecessary excision&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We present the RCM findings in 3 lesions with dermoscopic island &#40;a nevus-associated melanoma&#44; a melanocytic nevus&#44; and a melanoma in situ&#41;&#46; In 1 lesion&#44; examination of the area corresponding to the dermoscopic island revealed a globular pattern without cellular atypia on dermoscopy&#44; and the absence of cellular or architectural atypia on RCM&#46; In the other 2 lesions both dermoscopy and RCM revealed atypia in the area of the dermoscopic island&#44; and RCM showed isolated atypical round cells&#44; atypical cells forming nests&#44; discohesive nests&#44; and papillae with poorly defined contours at the dermoepidermal junction&#46; In all 3 cases&#44; RCM facilitated the diagnosis and management of melanocytic lesions with dermoscopic island&#46; RCM is useful for the study of lesions with dermoscopic island for 2 reasons&#58; this technique provides high-resolution images of the skin&#39;s most superficial layers &#40;to the level of the reticular dermis&#41;&#59; and dermoscopic island is mainly associated with fine melanoma&#44; melanoma in situ&#44; and nevus-associated melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Larger patient series could help further demonstrate the usefulness of RCM for the evaluation of these types of lesions&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0055" 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">The dermoscopic island is described as a well-defined area in a melanocytic lesion&#44; with a different dermoscopic pattern from the rest of the lesion&#46; It is predictive of melanoma&#44; particularly when the pattern of the island is atypical&#46; We present the reflectance confocal microscopy &#40;RCM&#41; findings in 3 lesions with dermoscopic islands&#58; nevus-associated melanoma&#44; melanocytic nevus&#44; and in situ melanoma&#46; The nevus-associated melanoma and in situ melanoma presented cellular atypia &#40;atypical cells in isolation or forming nests&#41; and architectural distortion on RCM&#46; The nevus presented a dermoscopic island with a typical globular pattern with dense nests and no atypia on RCM&#46; Dermoscopic island is mainly associated with in situ and nevus-associated melanomas&#46; RCM offers good cellular resolution to the depth of the reticular dermis and is useful for diagnosing of melanomas presenting a dermoscopic island&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El signo de la isla se define como un &#225;rea bien delimitada en una lesi&#243;n melanoc&#237;tica&#44; con un patr&#243;n dermatosc&#243;pico diferente al resto de la lesi&#243;n&#46; Es predictor de melanoma sobre todo cuando el patr&#243;n dermatosc&#243;pico de la isla es at&#237;pico&#46; Presentamos las caracter&#237;sticas con microscopia confocal de reflectancia &#40;MCR&#41; en un melanoma sobre <span class="elsevierStyleItalic">nevus</span>&#44; un <span class="elsevierStyleItalic">nevus</span> melanoc&#237;tico y un melanoma <span class="elsevierStyleItalic">in situ</span> con signo de la isla&#46; El melanoma sobre <span class="elsevierStyleItalic">nevus</span> y el melanoma <span class="elsevierStyleItalic">in situ</span>&#44; presentaban atipia celular &#40;c&#233;lulas at&#237;picas aisladas y formando nidos&#41; y distorsi&#243;n arquitectural por MCR&#46; El <span class="elsevierStyleItalic">nevus</span> presentaba un signo de la isla con un patr&#243;n globular t&#237;pico con nidos densos sin atipia por MCR&#46; El signo de la isla se relaciona sobre todo con melanomas <span class="elsevierStyleItalic">in situ</span> y melanomas sobre <span class="elsevierStyleItalic">nevus</span>&#46; El MCR ofrece una buena resoluci&#243;n celular hasta dermis reticular&#44; siendo &#250;til en el diagn&#243;stico de los melanomas con signo de la isla&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Elosua-Gonz&#225;lez M&#44; Gamo-Villegas R&#44; Florist&#225;n-Muruz&#225;bal U&#44; Pinedo-Moraleda F&#44; L&#243;pez-Estebaranz JL&#46; Microscopia confocal de reflectancia&#58; una herramienta &#250;til para diagnosticar malignidad en lesiones melanoc&#237;ticas que presenten el signo de la isla&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;e37&#8211;e41&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; dermoscopy&#44; and reflectance confocal microscopy &#40;RCM&#41; findings&#46; A&#44; Nevus with hyperpigmentation on the patient&#39;s back&#46; B&#44; Dermoscopic island&#58; dermoscopy reveals an area comprised of light brown globules with a homogeneous morphology and distribution&#44; in contrast to the reticular pattern observed throughout the rest of the lesion&#46; C&#44; RCM of the area corresponding to the globular dermoscopic pattern reveals a globular pattern consisting of dense nests &#40;arrows&#41; without atypia at the level of the dermoepidermal junction&#46; D&#44; The area corresponding to the reticular pattern presents a mesh-like pattern&#44; with no atypical cells&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; dermoscopy&#44; reflectance confocal microscopy &#40;RCM&#41;&#44; and histology findings&#46; A&#44; Lesion &#40;2<span class="elsevierStyleHsp" style=""></span>cm&#41; on the back of the right hand with a 6-<span class="elsevierStyleHsp" style=""></span>mm area of hyperpigmentation&#46; B&#44; Dermoscopy reveals a homogenous reticular pattern throughout most of the lesion&#44; and an atypical globular pattern corresponding to the area of eccentric hyperpigmentation&#46; C&#44; RCM of the area corresponding to the atypical globular pattern reveals papillae with poorly defined contours &#40;asterisks&#41;&#44; discohesive nests &#40;dots&#41;&#44; and atypical cells &#40;arrows&#41;&#46; D&#44; Melanoma in situ with a predominantly lentiginous pattern&#44; with single-cell pagetoid invasion &#40;asterisks&#41; and some groups of atypical cells &#40;arrows&#41; &#40;hematoxylin-eosin&#44; original magnification &#215;100&#41;&#46;</p>"
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                            2 => "C&#46; Ferrari"
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                            2 => "N&#46; Poulalhon"
                            3 => "B&#46; Balme"
                            4 => "S&#46; Dalle"
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