Dermoscopic evaluation of superficial spreading melanoma<sup>,</sup>

To describe the clinical and dermoscopic characteristics of superficial spreading melanomas, and to detect the differences between in situ and invasive 1-mm thick melanomas.

Methods:

This was a cross-sectional study in which dermoscopic images of 58 melanomas, grouped according to their thickness, were evaluated.

Results:

24 in situ melanomas were evaluated, 28 invasive melanomas with Breslow ≤ 1 mm (0.50 ± 0.22 mm) and six with Breslow > 1 mm (2.35 ± 2.02 mm). In situ melanomas were smaller than invasive melanomas. The most commonly found dermoscopic criteria were asymmetry (84.5%), three or more colors (81.0%), and atypical network (79.3%). A non-specific pattern was more common in in situ melanomas (p = 0.028) and atypical network in invasive melanomas with Breslow 1 mm presented inverted network (p = 0.018).

Study limitations:

The sample was selected by convenience, since it was necessary to have a preoperative photo of the tumor, which may have led to the loss of clinically less significant lesions, as well as those highly suggestive of melanoma.

Conclusions:

Melanomas in early stages showed a more frequent nonspecific pattern and atypical network, while invasive melanomas showed a multicomponent pattern, three or more colors, and an inverted network.

KEYWORDS
Dermoscopy; Melanoma; Skin neoplasms

Criterion	Definition
Contour, colors, and structure asymmetry	Inequality when the injury is divided into 0, 1, or 2 perpendicular axes.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Atypical pigmentary network	Irregular network with variation in color, thickness, and spacing of lines and holes, distributed asymmetrically.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Atypical dots and globules	Rounded or oval structures, with variation in color, size and shape; irregularly distributed in the lesion.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.^,²¹21 Kittler H, Marghoob A, Argenziano G, Carrera C, Curiel-Lewandrowski C, Hofmann-Wellenhof R, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-106.
Radial streaks and/or pseudopods	Linear structures or bulbous projections found at the edge of the lesion, which may be connected to the body of the tumor or to a pigmented network, brown to black in color.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.^,²¹21 Kittler H, Marghoob A, Argenziano G, Carrera C, Curiel-Lewandrowski C, Hofmann-Wellenhof R, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-106.
Whitish-blue veil	Irregular area, without structures, with "ground glass" whitish-blue color, which covers part of the lesion. Pigmentation cannot occupy the entire extent of the lesion.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Regression structures (white scar area and/or peppering)	Depigmented scar area with lighter coloration than normal skin and/or blue-grayish granules, described as a pepper-type pattern.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Hypopigmented area without structure	Hypopigmented area without peripheral structures occupying more than 10% of the lesion.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Blotch	Black, brown, or gray area, without structures.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
	Regular: blotch in the center of the lesion, surrounded by a pigmented network.²¹21 Kittler H, Marghoob A, Argenziano G, Carrera C, Curiel-Lewandrowski C, Hofmann-Wellenhof R, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-106.
	Irregular: more than one blotch, or a blotch with peripheral location.²¹21 Kittler H, Marghoob A, Argenziano G, Carrera C, Curiel-Lewandrowski C, Hofmann-Wellenhof R, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-106.
Atypical vases	Dotted, irregular linear, or polymorphic vessels.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Inverted network	Hypopigmented network in which the light areas form the beams and the pigmented areas fill the holes.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95. 21 Kittler H, Marghoob A, Argenziano G, Carrera C, Curiel-Lewandrowski C, Hofmann-Wellenhof R, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-106. 22 Di Stefani A, Campbell TM, Malvehy J, Massone C, Soyer HP, Hofmann-Wellenhof R. Shiny white streaks: An additional dermoscopic finding in melanomas viewed using contact polarised dermoscopy. Australas J Dermatol. 2010;51:295-8. 23 Shitara D, Ishioka P, Alonso-Pinedo Y, Palacios-Bejarano L, Carrera C, Malvehy J, et al. Shiny white streaks: a sign of malignancy at dermoscopy of pigmented skin lesions. Acta Derm Venereol. 2014;94:132-7.^-²⁴24 Pizzichetta MA, Talamini R, Marghoob AA, Soyer HP, Argenziano G, Bono R, et al. Negative pigment network: an additional dermoscopic feature for the diagnosis of melanoma. J Am Acad Dermatol. 2013;68:552-9.
Milky-red area	Globule and/or larger area of a milky-red color, blurred or unfocused, which corresponds to an elevated part of the lesion.²⁵25 Argenziano G, Zalaudek I, Corona R, Sera F, Cicale L, Petrillo G, et al. Vascular structures in skin tumors: a dermoscopy study. Arch Dermatol. 2004;140:1485-9. It consists of a vascular pattern, without specific distinguishable vessels.²¹21 Kittler H, Marghoob A, Argenziano G, Carrera C, Curiel-Lewandrowski C, Hofmann-Wellenhof R, et al. Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-106.
Dermoscopic island	Circumscribed area with uniform pattern that differs from the rest of the lesion.²⁶26 Borsari S, Longo C, Ferrari C, Benati E, Bassoli S, Schianchi S, et al. Dermoscopic island: a new descriptor for thin melanoma. Arch Dermatol. 2010;146:1257-62.
Reticular bluish-gray area	Coarse bluish-gray net, with thick lines and large holes.²⁷27 Seidenari S, Ferrari C, Borsari S, Benati E, Ponti G, Bassoli S, et al. Reticular grey-blue areas of regression as a dermoscopic marker of melanoma in situ. Br J Dermatol. 2010;163:302-9.^,²⁸28 Bassoli S, Borsari S, Ferrari C, Giusti F, Pellacani G, Ponti G, et al. Grey-blue regression in melanoma in situ-evaluation on 111 cases. J Skin Cancer. 2011;2011:180980.
Presence of multiple colors	Presence of three or more colors, including black, light brown, dark brown, blue, red, white, and gray.

Pattern	Definition
Multicomponent pattern	Presence of three or more criteria.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Non-specific pattern	Pigmented lesion without a specific pattern.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Reticular pattern	Pigmented network covering most of the lesion.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Globular pattern	Numerous globules of varying sizes with brown and/or blackish-gray tones.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Starburst pattern	Radial streaks and/or pseudopods in radial arrangement at the edge of the lesion.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.
Homogeneous pattern	Diffuse brown, blue or grayish-black pigmentation in the absence of other local structures.²⁰20 Malvehy J, Puig S, Argenziano G, Marghoob AA, Soyer HP. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007;57:84-95.

Clinical aspects	In situ	≤ 1 mm	> 1 mm	Total	Comparisons (p-values)
Clinical aspects	In situ	≤ 1 mm	> 1 mm	Total	General between 3 groups	In situ vs. invasive	≤ 1 mm vs. > 1 mm
Tumor size (n)	14	18	6	38
< 6 mm	5 (35.7%)	0 (0%)	0 (0%)	5 (13.2%)	0.009	0.004	-
≥ 6 mm	9 (64.3%)	18 (100%)	6 (100%)	33 (86.8%)
Location (n)	24	28	6	58
Face	0 (0%)	0 (0%)	2 (33,3%)	2 (3.5%)	0.120	0.568	0.083
Cervical	1 (4.2%)	2 (7.1%)	0 (0%)	3 (5.2%)
Trunk	16 (66.7%)	16 (57.1%)	4 (66.7%)	36 (62.1%)
Upper limbs	1 (4.2%)	4 (14.3%)	0 (0%)	5 (8.6%)
Lower limbs	6 (25.0%)	6 (21.4%)	0 (0%)	12 (20.7%)

Dermatoscopic criteria	In situ	≤ 1 mm	> 1 mm	Total	Comparisons (p)
Dermatoscopic criteria	In situ	≤ 1 mm	> 1 mm	Total	General	In situ vs. invasive	≤ 1 mm vs. > 1 mm
Asymmetry (n)	24	28	6	58
No	3 (12.5%)	5 (17.9%)	1 (16.7%)	9 (15.5%)	0.877	0.722	1.000
Yes	21 (87.5%)	23 (82.1%)	5 (83.3%)	49 (84.5%)
Atypical network (n)	24	28	6	58
No	7 (29.2%)	2 (7.1%)	3 (50.0%)	12 (20.7%)	0.020	0.181	0.029
Yes	17 (70.8%)	26 (92.9%)	3 (50.0%)	46 (79.3%)
Atypical dots/globules (n)	24	28	6	58
No	10 (41.7%)	10 (35.7%)	3 (50.0%)	23 (39.7%)	0.783	0.792	0.653
Yes	15 (58.3%)	18 (64.3%)	3 (50.0%)	36 (60.3%)
Streaks/pseudopods (n)	24	28	6	58
No	16 (66.7%)	18 (64.3%)	5 (83.3%)	39 (67.2%)	0.548	0.938	0.638
Yes	8 (33.3%)	10 (35.7%)	1 (16.7%)	19 (32.8%)
Veil (n)	24	28	6	58
No	18 (75.0%)	14 (50.0%)	3 (50.0%)	35 (60.3%)	0.163	0.055	1.000
Yes	6 (25.0%)	14 (50.0%)	3 (50.0%)	23 (39.7%)
Regression structures (n)	24	28	6	58
No	20 (83.3%)	23 (82.1%)	5 (83.3%)	48 (82.8%)	0.993	0.922	1.000
Yes	4 (16.7%)	5 (17.9%)	1 (16.7%)	10 (17.2%)
Hypopigmented area (n)	24	28	6	58
No	21 (87.5%)	24 (85.7%)	5 (83.3%)	50 (86.2%)	1.000	1.000	1.000
Yes	3 (10.5%)	4 (14.3%)	1 (16.7%)	8 (13.8%)
Blotchs (n)	24	28	6	58
No	20 (83.3%)	24 (85.7%)	5 (83.3%)	49 (84.5%)	0.938	0.675	1.000
Yes	4 (16.7%)	4 (14.3%)	1 (16.7%)	9 (15.5%)
Atypical vessels (n)	24	28	6	58
No	19 (79.2%)	21 (75.0%)	5 (83.3%)	45 (77.6%)	0.904	0.808	1.000
Yes	5 (20.8%)	7 (25.0%)	1 (16.7%)	13 (22.4%)
Inverted network (n)	24	28	6	58
No	22 (91.7%)	24 (85.7%)	2 (33,3%)	48 (82.8%)	0.009	0.131	0.018
Yes	2 (8.3%)	4 (14.3%)	4 (66,7%)	10 (17.2%)
Milky red area (n)	24	28	6	58
No	16 (66.7%)	16 (57.1%)	5 (83.3%)	37 (63.8%)	0.491	0.702	0.370
Yes	8 (33.3%)	12 (42.9%)	1 (16.7%)	21 (36.2%)
Dermoscopic island (n)	24	28	6	58
No	22 (91.7%)	27 (96.4%)	6 (100%)	55 (94.8%)	0.706	0.564	1.000
Yes	2 (8.3%)	1 (3.6%)	0 (0%)	3 (5.2%)
Reticular bluish-gray area (n)	24	28	6	58
No	24 (100%)	25 (89.3%)	6 (100%)	55 (94.8%)	0.325	0.260	1.000
Yes	0 (0%)	3 (10.7%)	0 (0%)	3 (5.2%)
3 or + colors (n)	24	28	6	58
No	8 (33.3%)	3 (10.7%)	0 (0%)	11 (19.0%)	0,078	0.019	1.000
Yes	16 (66.7%)	25 (89.3%)	6 (100%)	47 (81.0%)

Dermoscopic patterns	In situ	≤ 1 mm	> 1 mm	Total	Comparisons (p)
Dermoscopic patterns	In situ	≤ 1 mm	> 1 mm	Total	General	In situ vs. invasive	≤ 1 mm vs. > 1 mm
Multicomponent (n)	24	28	6	58
No	16 (66.7%)	9 (32.1%)	3 (50.0%)	28 (48.3%)	0.062	0.026	0.641
Yes	8 (33.3%)	19 (67.9%)	3 (50.0%)	30 (51.7%)
Non-specific (n)	24	28	6	58
No	19 (79.2%)	27 (96.4%)	6 (100%)	52 (89.7%)	0.136	0.028	1.000
Yes	5 (20.8%)	1 (3.6%)	0 (0%)	6 (10.3%)
Reticular (n)	24	28	6	58
No	19 (79.2%)	21 (75.0%)	5 (83.3%)	45 (77.6%)	0.904	0.808	1.000
Yes	5 (20.8%)	7 (25.0%)	1 (16.7%)	13 (22.4%)
Globular (n)	24	28	6	58
No	22 (91.7%)	27 (96.4%)	5 (83.3%)	54 (93.1%)	0.307	1.000	0.362
Yes	2 (8.3%)	1 (3.6%)	1 (16.7%)	4 (6.9%)
Starburst (n)	24	28	6	58
No	21 (87.5%)	28 (100%)	5 (83.3%)	54 (93.1%)	0.103	0.297	0.176
Yes	3 (12.5%)	0 (0%)	1 (16.7%)	4 (6.9%)
Homogeneous (n)	24	28	6	58
No	23 (95.8%)	28 (100%)	6 (100%)	57 (98.3%)	0.517	0.414	-
Yes	1 (4.2%)	0 (0%)	0 (0%)	1 (1.7%)

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[1] * Corresponding author. E-mail: fmarquestrindade@gmail.com (F.M. Trindade).