Dermatology: Practical and Conceptual Observation | Dermatol Pract Concept 2014;4(3):7 43 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com It has been observed that a patient’s “normal” moles resemble each other clinically. This concept also applies to dermoscopic observations, as shown by our previous demonstration that an individual’s nevi tend to have one to three predominant overall dermoscopic patterns [1]. A recent study investigated and compared the dermo- scopic patterns of multiple primary melanomas (MPMs) in a large series of patients [2]. The authors showed that MPMs of elderly patients with sun-damaged skin were often dermoscopically similar in pigment network and regression structures. This observation is intriguing because it suggests that a rule valid for the nevi of an individual (all nevi have a similar dermoscopic pattern, typical or otherwise), may also be valid for melanomas: i.e., in a given individual, melanomas in similar anatomical sites have similar dermoscopic patterns [3]. However, the authors mainly assessed thin melanomas and admitted this as a limitation of their study: “Thin and superficial spreading melanomas were predominant in our study population.” In the last five years we had the opportunity of observing five patients over 70 years of age with multiple melanomas (multifocal), thicker than 2 mm, located in photo-damaged areas (Figure 1-4) (Table 1). We evaluated the dermoscopic images of these pigmented skin lesions retrospectively. The images were taken using a photo camera equipped with a polarized contact dermoscope (DermLite® Photo 3Gen, San Juan Capistrano, CA, US). All images were analyzed by an expert dermoscopist (P.R.). Lesions were evaluated for eight dermoscopic features, as reported in Table 1. As suggested by Moscarella et al. [2], similar appearance was defined as the same dermoscopically detected features with similar scores and/or with a difference in only one minor feature (a feature present in less than 10% of the lesion). Dif- ferent appearance was defined as different dermoscopically detected features with different scores in all melanomas of a given patient. Features in a given lesion were quantified as present in < 10%, 10-50% and > 50% of the lesion. Five patients (3 males) with a total of 12 melanomas were collected from the databases of three skin clinics. Age ranged from 70 to 84 years (mean 76.6 years). Three patients (60%) had two, and two patients (40%) had three primary melano- mas. Mean Breslow thickness was 2.8 mm. As reported in Table 2, in all our cases, the melanomas of a given patient shared very similar dermoscopic features and scores (Table 2) (Fig 1 a, b, c). We classified patients as having melanomas with similar or different dermoscopic features on Multiple primary thick melanomas: similar dermoscopic pattern Luca Feci1, Michele Fimiani1, Pietro Rubegni1 1 Department of Clinical Medicine and Immunological Sciences, Dermatology Section, University of Siena, Siena, Italy Keywords: dermoscopy, melanoma, multiple melanomas Citation: Feci L, Fimiani, Rubegni P. Multiple primary thick melanomas: similar dermoscopic pattern. Dermatol Pract Concept. 2014;4(3):7. http://dx.doi.org/10.5826/dpc.0403a07 Received: October 3, 2013; Accepted: March 18, 2014; Published: July 31, 2014 Copyright: ©2014 Feci et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Dr. Pietro Rubegni, Dept. of Clinical Medicine and Immunological Science—Dermatology Section, Policlinico “Le Scotte” Viale Bracci—53100 Siena, Italy. Tel. +39 0577 40190. E-mail: rubegni@unisi.it 44 Observation | Dermatol Pract Concept 2014;4(3):7 Dr. Pietro Rubegni provided substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; Dr. Luca Feci and Dr. Pietro Rubegni drafted the article and revised it critically for intellectual content; Prof. Michele Fimiani provided final approval of the version to be published. the basis of lesion scores. In particular, 4/5 patients (80%) showed melanomas that were dermoscopically similar, and 1/5 (20%) had melanomas that were dermoscopically different. In line with the experience described in Moscarella et al., our results suggest that the principles valid for nevi of a given individual (all nevi have similar dermoscopic pattern, typical or otherwise) might also be valid for thick and thin melanomas [3]. However, thick melanomas may tend to be similar by nature. Although our case series is too small for any statistical analysis, our preliminary results seem to cor- roborate the results of Moscarella and colleagues. Figure  1. (a) Clinical appearance of two similar synchronous melanomas occurring on the back of a 77-year-old man; (b & c) Dermoscopic images of the melanomas: Breslow thickness 3.1 mm (b) and 2.2 mm (c). The lesions had the same dermoscopic features: atypical pigmented network, regression struc- tures (chrysalis), eccentric globules, atypical vascular pattern and blue/white veil. [Copyright: ©2014 Feci et al.] Figure 2. (a) Clinical appearance of two similar synchro- nous melanomas occurring on the back of a 74-year-old man; (b & c) Dermoscopic images of the melanomas: Breslow thickness 3.8 mm (b) and 2.4 mm (c). The le- sions had the same dermoscopic features characterized by blue/white veil, structureless areas and regression structures. [Copyright: ©2014 Feci et al.] Figure  3. Two similar melanomas occurring one on the back (a) and one on the left lower leg (b) of a 70-year-old woman; (a & b) Dermoscopic images of the melanomas: Breslow thickness 3.5 mm (a) and 2.7 mm (b). The lesions had the same dermoscopic features characterized by blue/white veil, structureless areas and regression structures. [Copyright: ©2014 Feci et al.] Figure 4. Three similar melanomas occurring two on the back (a, b) and one on the right lower leg (c) of a 78-year-old man; (a, b, c) Der- moscopic images of the melanomas: Breslow thickness 3.0 mm (a), 2.2 mm (b) and 2.4 mm (c). The lesions had the same dermoscopic features characterized by blue/white veil, structureless areas, streaks and peripheral globules more evident in Figures b and c. [Copyright: ©2014 Feci et al. Observation | Dermatol Pract Concept 2014;4(3):7 45 TABLE 1. Dermographic data of the patients [Copyright: ©2014 Feci et al.] Name Sex Age (years) Location Type of melanoma Thickness of melanoma (mm) A.M. M 77 1) Trunk 2) Trunk 1) Invasive superficial spreading melanoma 2) Invasive superficial spreading melanoma 1) 3.1 2) 2.2 L.R. M 74 1) Trunk 2) Trunk 1) Nodular melanoma 2) Nodular melanoma 1) 3.8 2) 2.4 N.F. F 70 1) Trunk 2) Lower leg 1) Invasive superficial spreading melanoma 2) Invasive superficial spreading melanoma 1) 3.5 2) 2.7 M.M. F 84 1) Trunk 2) Trunk 3) Upper harm 1) Invasive superficial spreading melanoma 2) Invasive superficial spreading melanoma 3) Invasive superficial spreading melanoma 1) 3.1 2) 3.0 3) 2.2 C.R. M 78 1) Trunk 2) Trunk 1) Lower leg 1) Invasive superficial spreading melanoma 2) Invasive superficial spreading melanoma 3) Invasive superficial spreading melanoma 1) 3.0 2) 2.2 3) 2.4 TABLE 2. Evaluation and scores of the dermoscopic features [Copyright: ©2014 Feci et al.] % of the feature Network (%) Inverse network (%) Regression structures (%) dots/ globules (%) Structureless (%) Vascular pattern (%) Blue/ white veil (%) Streaks (%) < 10% 6 (42.8) 2 (14. 2) 1 (8.3) 3 (21.4) 1 (8.3) 2 (14.2) 0 5 (35.7) 10-50% 4 (28.6) 0 6 (50) 1 (7.1) 5 (41.7) 6 (42.8) 3 (25) 2 (14.2) > 50% 0 0 5 (41.7) 0 6 (50) 5 (35.7) 9 (75) 0 Total 10 (71.4) 2 (14.2) 12 (100) 4 (28.6) 12 (100) 13 (92.8) 12 (100) 7 (50) References 1. Scope A, Burroni M, Agero AL, et al. Predominant dermoscopic patterns observed among nevi. J Cutan Med Surg. 2006;10:170-4. 2. Moscarella E, Rabinovitz H, Puig S, et al. Multiple primary mela- nomas: do they look the same? Br J Dermatol. 2013;168:1267-72. 3. Burroni M, Dell’Eva G, Corona R, et al. Inter- and intra-variability of pigmented skin lesions: could the ABCD rule be influenced by host characteristics? Skin Res Technol. 2004;10:193-9.