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病例漫谈10:一例小型浸润性黑色素瘤的皮肤镜检查和皮肤病理学分析病例报告 [复制链接]


A tiny invasive melanoma: a case report with dermatoscopy and dermatopathology



         We present a case of an early invasive melanoma (Breslow thickness 0.25 mm), 1.6 mm in diameter on the arm of a 38-year-old woman. She was under surveillance due to having multiple (100) nevi, and the melanoma was assessed as a new lesion by the examining doctor. Clinically the lesion was hyper¬pigmented compared with surrounding nevi and dermatoscopically it had a clue of pseudopods/lines radial, but they were arranged in an arguably symmetrical circumferential pattern around a structure¬less blue-gray center. Generally melanomas are expected to be dermatoscopically asymmetrical, but we believe that this case illustrates the fact that small melanomas may be recognized by clues such as pseudopods/lines radial and dermatoscopic gray even when they have not yet developed unequivocal asymmetry.
       我们报道了一例38岁女性患者,上肢出现早期浸润性黑色素瘤,厚度0.25 mm,直径1.6 mm。由于具有许多色素痣(大于100),该患者一直处于监测中;检测医师将此处的黑色素瘤视为新发皮损。临床上来看,此处的黑色素瘤比周边色素痣颜色深;皮肤镜检查显示,其伪足/径向线围绕不定形蓝灰色中心排列成圆周对称图案。通常情况下,黑色素瘤的皮肤镜检查结果都是呈非对称图案,但是我们通过这一病例来阐明,即使一些小型黑色素瘤尚未发展为明显不对称型,我们也可以通过诸如伪足/径向线,以及镜检的灰色结果来进行疾病诊断。

         The diagnosis of melanomas smaller than 4 mm presents dif¬ficulties because the clinical and dermatoscopic features of small melanomas have been reported infrequently.
       目前,关于小型黑色素瘤的临床特征和皮肤镜检特征的报道较少,因此,诊断小于4 mm的黑色素瘤仍存在困难。

Case report
         A 38-year-old Australian-born woman of Italian descent, with Fitzpatrick type 4 skin, presented for a routine yearly skin examination. She was examined with a Heine Delta 20 dermatoscope (Heine, Optotechnic GmbH, Herrsching, Germany) and had been having total body photography with a Molemax Dermdoc video monitoring system (Derma Medical Systems, Austria). In previous years some pigmented lesions (PSLs) had been observed to change with symmet¬rical growth of peripheral clods. These were deemed to be maturing nevi and had not been excised. One pigmented skin lesion had been excised in 2007 and was reported by the pathologist to be an irritated dysplastic nevus.
       一名意大利裔澳大利亚籍的38岁女性,属于Fitzpatrick 4型皮肤,前来进行每年例行的皮肤检查。医生使用Heine Delta 20皮肤镜(Heine, Optotechnic GmbH, Herrsching, Germany)对其进行镜检,并用Molemax Dermdoc视频监控系统(Derma Medical Systems, Austria)进行全身摄影。往年检查发现,有些色素性皮损会随着周边斑块的对称性增长而发生变化。专家认为这些皮损属于成熟性痣,并未将其切除。2007年,该患者发现有一处皮肤色素性皮损,病理学家称其会发展为炎性发育不良痣,故将其切除。

     At this visit in May 2012, a new lesion was detected on the left arm (Figure 1A). Clinically it was noted to be darker than surrounding PSLs and dermatoscopically pseudopods and radial lines were arranged circumferentially around a structureless blue-gray center (Figure 1B); the radial lines were arguably symmetrically distributed, appearing in all quadrants of the perimeter while being less clearly defined and sparser in one quadrant. This lesion was new at mature age (evolving), which raised suspicion for malignancy despite the lesion’s small size and equivocal symmetry [1].
        2012年5月,患者前来就诊,医生在其左臂检查出一处新发皮损(图1A)。临床上来看,该皮损比色素性皮损颜色深;镜检显示,伪足和经向线围绕无定形蓝灰色中心分布(图1B)。经向线看似呈现对称性分布,在视野镜里所有象限均有出现,但某些象限中,经向线较为稀疏、不太清晰。虽然该皮损部位很小,并呈现不明显对称性分布,但由于发生在成年人身上,很有可能发展成为恶性肿瘤 [1]。

Figure 1. (A) Clinical image and (B) dermatoscopic image of a new pigmented skin lesion


      The lesion was subjected to excision biopsy and dermatopathologic assessment (Figure 2 composite) showed a small, but asym¬metric, nested and single cell proliferation of atypical melanocytes along the dermoepidermal junction with scattered single cell intraepithelial upward spread. There was limited extension into the papillary dermis to a depth of 0.25 mm. Superficial dermal melanosis and inflammation were pres¬ent along with mild fibroplasia, suggesting a component of regression to a depth of 0.35 mm.
        医生切除该皮损,并进行活组织切片检查和皮肤镜评定(图2),结果显示,非典型黑色素细胞的小型不对称巢状单细胞增殖,沿真皮表皮连接处向单细胞上皮向上扩散分布。少数细胞延伸至乳突真皮层0.25 mm。浅表皮肤发现黑色素沉着症和炎症,并伴发轻度纤维增生,提示衰变部位深达0.35 mm。

       In spite of the dermato¬scopic appearance of lines radial circumferential, there were no spitzoid features dermatopathologically. The diagnosis of early level 2 malignant melanoma of superficial spreading type was rendered. Physical examination revealed no evi¬dence of lymphatic or systemic metastasis and the patient will have routine clinical and dermatoscopic surveillance in accordance with current guidelines [2].
       皮肤镜检查显示,皮损部位沿径向线呈圆周分布,但是,皮肤病理学分析并无恶化的迹象。医生提供了2级早期浅表扩散型恶性黑色素瘤的诊断指南。由于患者的身体检查并未发现淋巴或全身性转移,病人将会按当前指南进行常规临床检查和皮肤镜检查 [2]。

       A proportion of melanomas have been found not to fit the D criterion of the ABCD acronym, where D stands for a diameter of 6 mm or greater. Such small melanomas have a reported frequency of 11.4-38.2% of all melanomas [3-6]. One review in particular, published in 2004, found that small melanomas include less than 1 to 38% of all invasive mela¬nomas [1] and it recommended that the ABCD acronym be modified to ABCDE with “E” to stand for “evolving.”
       有一定比例的黑色素瘤尚不符合ABCD 首字母缩略词中的D标准,此处,D代表黑色素瘤的直径大于等于6 mm。这些小型黑色素瘤约占所有报道过黑色素瘤的11.4-38.2%[3-6]。尤其是2004年发表的一篇综述,指出小型黑色素瘤占所有浸润性黑色素瘤的1%-38%[1];同时,该文章还建议ABCD应当修改为ABCDE,其中“E”代表“演变”。

     Previously the dermatoscopic features of an in-situ mela¬noma with a diameter of 1.6 mm were reported [7]. Published dermatoscopy images revealed that even at this minute size there was unequivocal asymmetry of structure and the pres¬ence of the dermatoscopic clue to melanoma of gray dots. It satisfied the criteria for malig¬nancy of the 3-point checklist [8], the Menzies method [9] and Chaos and Clues [10]. Teng et al reported the dermatoscopic features of an in-situ melanoma with a diameter of 2 mm [11]. A published derma¬toscopy image revealed unequivo¬cal asymmetry of both color and structure with some lines radial segmental and blue-gray structures.
         之前有报道称,皮肤经检查发现一处直径为1.6 mm的原位黑色素瘤[7]。其皮肤镜图像显示,即便尺寸微小,该黑色素瘤仍表现为明显不对称结构;同时,镜检结果的灰色圆点也提示患有黑色素瘤。这满足了恶性肿瘤的几个标准,“三点清单”[8],Menzies法[9]以及Chaos和Clues标准[10]。Teng等人报道了一例直径为2 mm的原位黑色素瘤的皮肤镜检特征[11]。其皮肤镜图像显示,黑色素瘤颜色和结构呈明显不对称,并有节段性径向线和蓝灰色结构。

     In the case that we report, the lesion was noted to be hyperpig¬mented compared to surrounding PSLs. One previous study reported that intensity of dark pigmentation was the defining clinical charac¬teristic in each of 13 (including 5 invasive) small melanomas (<4 mm diameter) in a series of 95 melano¬mas [5], although this may in fact be due to selection bias as minute dark melanomas are more likely to be noticed and assessed in comparison to small pale melanomas which may be present but not detected.
        我们报道的病例中,可以注意到皮损部位比周边色素性皮损部分颜色深。先前的一项研究报道,在95例黑色素瘤中,有13例(包括5例浸润性)小型黑色素瘤(直径小于4 mm)的深色色素沉着强度呈现典型的临床特征。事实上,这可能是选择偏倚所致。与那些可能存在却未被发现的色素沉着较浅的小型黑色素瘤相比,这些深色的黑色素瘤更容易被发现并进行评定。

     The case reported here, unlike the two previously reported smallest in-situ melanomas [7,11] did not exhibit unequivocal dermatoscopic asymmetry, and this is significant because dermatoscopic asymmetry is a generally accepted criterion for all of the published clinical and dermatoscopic algorithms. However in one study of consecutive pigmented skin lesions with a maximum diameter of 6mm (range 3-6 mm) excised in a specialized university dermatology depart¬ment over four years, 34 out of a total of 103 melanocytic lesions were melanomas [12], and of those 34 melanomas only 11 (32.4%) were asymmetrical. This supports the need to assess small PSLs without the required algorithmic crite¬rion of asymmetry.
        该病例不像之前报道的两例最小原位黑色素瘤[7,11],皮肤镜并未观察到明显不对称性。这一点非常重要,因为皮肤镜下显示非对称性是所有已发布临床和皮肤镜法则都普遍适用的标准。一所专业大学的皮肤科进行了一项连续四年之久的研究,切除的色素性皮损的最大直径为6mm(范围3-6 mm)。研究发现总共有103处黑色素细胞皮损,其中34处是黑色素瘤[12],而仅有11例(32.4%)呈现非对称性分布。这项研究能够满足不需非对称性标准评定的小型色素性皮损的评定需要。

     In one pilot study of 28 diagnosed melanomas less than or equal to 4 mm in diameter, there were only 14 (50%) that were unanimously diagnosed as melanomas by each of three dermatopathologists [13]. The dermatopathologic criteria of these were evaluated. The criteria regarded as most sig¬nificant included pagetoid spread (n=9/14), irregular nesting (n=9/14), predominance of individual junctional melanocytes (n=6/14) and cytological atypia (n=13/14). The very small melanoma we present in this case report exhibited all of these features as well as poor maturation in the invasive portion with pigmentation and nesting to the base of the lesion.
        在一项28例黑色素瘤(直径小于或等于4 mm)的初步研究中,通过三次皮肤镜检仅有14 (50%)例被一致性诊断为黑色素瘤[13]。研究也对这些皮肤镜的标准加以评定。最有效的标准包括变形性骨炎样扩散(n=9/14)、不规则巢状(n=9/14)、黑色素细胞个体交叉表型(n=6/14)和细胞学的异型性(n=13/14)。我们报道的这例小型黑色素瘤呈现了所有特征,以及皮损基础上的色素沉着和巢状浸润。

      The melanoma reported here had the same diameter, of 1.6 mm, as the previously smallest reported melanoma with dermatoscopic images, but it differed in that it was inva¬sive. As has been previously reported with small melanomas, it was darker than surrounding nevi but this may be due to selection bias. We regard it as very significant that this melanoma did not have unequivocal asymmetry, although it did have recognized clues to malignancy, including the presence of gray color and radial lines/pseudopods, albeit arranged in a circumferential pattern. We believe that very small pigmented lesions which have any recognized clues to melanoma should be assessed for biopsy whether or not unequivocal asymmetry is present.
        我们报道的黑色素瘤直径为1.6 mm,与之前皮肤镜图像报道的最小黑色素瘤直径相同,但是该黑色素瘤具有浸润性。以前也有关于小型黑色素瘤的报道,称其比周边色素痣颜色深,但这可能是选择偏倚所致。尽管此处的黑色素瘤未见明显的非对称性,但是这一特点具有重要的意义,结合灰色斑点和圆周分布的径向线/伪足,提示可能发展为恶性肿瘤。我们认为,对于有可能发展为黑色素瘤的小型色素性皮损,都应当进行活组织检查,并评定其是否具有明显的非对称性。


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