DR [page 20] [Dermatology Reports 2011; 3:e10] Dermatology Reports 2011; volume 3:e10 The important role of interdisciplinary collaboration in the management of a melanocytic skin lesion Anna Balato,1 Annunziata Raimondo,1 Mariateresa Cantelli,1 Maria Siano,2 Serena Lembo,1 Massimiliano Scalvenzi,1 Nicola Balato1 1Department of Dermatology, University of Naples Federico II, Naples, Italy; 2Department of Biomorphological and Functional Sciences, Pathology Section, School of Medicine, University Federico II of Naples, Naples, Italy Abstract One of the most confounding characteris- tics, commonly seen in malignant, but even in benign melanocytic nevi, is represented by the regression phenomenon. The identification of regression, through dermoscopical observa- tion, can be predictive of a tricky histopatho- logical examination. Therefore, this feature should be an alert to a meticulous clinical, der- moscopical and histopathological correlation for correct analysis of melanocytic skin lesions. A 26-year-old man was referred to our department for a pigmented skin lesion local- ized on his trunk. It was clinically and dermo- scopically diagnosed as atypical melanocytic nevus with central regression. After 1 year the lesion underwent considerable changes, lead- ing to a nearly complete regression. The lesion was excised and, on the basis of clinical, der- moscopical and histopathological correlation, was interpreted as a junctional melanocytic nevus with regression. In our case the associ- ation of clinical, dermoscopical and histopathological experience, resulted an important and useful method, in order to prop- er interpret and correctly diagnose an atypical melanocytic skin lesion. In November 2009, a 26-year-old man was referred to our department for a pigmented skin lesion on his trunk. The lesion appeared as a brown macule, sized 5 mm in diameter, with an irregular shape and no associated pru- ritus or discomfort. Family history of dysplastic nevi or melanoma was negative. Dermoscopic examination showed: reticular pattern with central regression, constituted by blue-white areas, and diffuse dots/globules (Figure 1a). A diagnosis of atypical melanocytic nevus with partial regression was made and excision of the lesion was recommended, but the patient did not show up, even after several reminders. He presented for a follow up after 1 year, when the lesion was almost totally disappeared. It was dermoscopically re-analyzed revealing dif- fuse white area with only a small central resid- ual light brown pigmentation network (Figure 1b). The lesion was finally excised and histopathologic examination performed, diag- nosing it as a melanocytic blue nevus. Since there was no concordance between histo - pathology, dermoscopy and clinical history the specimen was re-analyzed histopathologically. The examination confirmed the presence of fibrosis, neovascularization and heavily-pig- mented dendritic melanocytes in the dermis (Figure 1c), but it showed also areas with irregular junctional melanocytic activity with a focal trend toward the upward spreading (page- toid). The dermal component was constituted of melanocytes with small round nuclei, with rare nucleoli, and showed a solid growth pat- tern, with deep nodular areas characterized by high cellularity, without significant atypia (Figure 1d). This component showed a striking immunoreactivity for S-100 protein and ki-67 (MIB-1), but it was negative for HMB45. Based on the review of clinical, dermoscopical and histopathological features, the lesion was now diagnosed as a junctional melanocytic nevus with regression. A strict follow-up every 6 months was recommended. The regression phenomenon represents one of the most confounding characteristics, com- monly seen in malignant, but even in benign melanocytic nevi. It has been reported in the literature using various terms and definitions, reflecting the great morphological variability of this phenomenon. The presence of regres- sion might be confounding not only on dermo- scopic grounds but also on histopathological Correspondence: Serena Lembo, Department of Dermatology - University of Naples Federico II via S. Pansini 5, 80131 Naples, Italy. Tel. +39.081.7462457 - Fax +39.081.7462442. E-mail: serenalembo@yahoo.it Key words: melanocytic skin lesion, dermoscopy, histopathology, regression, interdisciplinary col- laboration. Conflict of interest: the authors report no con- flicts of interest. Received for publication: 30 May 2011. Revision received: 20 June 2011. Accepted for publication: 22 June 2011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright A. Balato et al., 2011 Licensee PAGEPress, Italy Dermatology Reports 2011; 3:e10 doi:10.4081/dr.2011.e10 Figure 1. (a) Dermoscopic examination at the first observation and (b) after 1 year. Histopathological examination: (c) fibrosis, neovascularization and heavily-pigmented dendritic melanocytes in the dermis (arrows) (hematoxylin and eosin stain; H&E, X10- 20 magnification); (d) irregular junctional melanocytic activity with a focal trend toward the upward spreading (pagetoid) (arrow). In the dermis presence of melanocytes with small round nuclei, rare nucleoli, and a solid growth pattern with high cellularity, but no significant atypia (hematoxylin and eosin stain; H&E, X20-40). No n- co mm er cia l u se on ly [Dermatology Reports 2011; 3:e10] [page 21] Article ones. Zalaudek et al.1 showed an absolute cor- respondence between the dermoscopic blue- white structures and the presence of partial or focal regression histopathologically. Ackerman et al.2 reported a dermoscopical - histopatho- logical correlation between blue areas and the melanosis type of regression as well as between white areas and the fibrosis type of regression. Our case completely fitted with these findings. In the last two decades several studies have been performed investigating the diagnostic impact of dermoscopy, demonstrating the increase of accuracy in diagnosing pigmented skin lesions compared with clinical examina- tion by the naked eye.3,4 However, dermoscopy is not 100% accurate in differentiating melanocytic skin lesions as these entities fre- quently are characterized by ‘overlapping’ der- moscopic features.5,6 The loss of typical dermo- scopic features over time, as in our case, rep- resents a challenge for the dermatologist. Ferrara et al.7 showed that the presence of fea- tures as regression in melanocytic lesions might lead to an interobserver disagreement on diagnosis from a dermoscopical but also histopathological point of view. The knowledge of a dermoscopic pattern which might be pre- dictive of a histopathological difficulty for the analysis of melanocytic skin lesions should be an alert to a meticulous clinical, dermoscopical and histopathological correlation.8 This report confirmed this correlation as an important and useful method in order to interpret and diag- nose an atypical melanocytic skin lesion. In conclusion, we want to emphasize the impor- tant role of the interdisciplinary collaboration in the management of melanocytic skin moles. References 1. Zalaudek I, Argenziano G, Ferrara G, et al. Clinically equivocal melanocytic skin lesions with features of regression: a der- moscopic–pathological study. Br J Dermatol 2004;150:64-71. 2. Ackerman AB, Cerroni L, Kerl H. Pitfalls in Histopathologic Diagnosis of Malignant Melanoma. Philadelphia: Lea & Febiger;1994. 3. Mayer J. Systematic review of the diagnos- tic accuracy of dermatoscopy in detecting malignant melanoma. Med J Aust 1997; 167:206-10. 4. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159-65. 5. Hofmann-Wellenhof R, Blum A, Wolf IH, et al. Dermoscopic classification of atypical melanocytic nevi (Clark nevi). Arch Dermatol 2001;137:1575-80. 6. Argenziano G, Scalvenzi M, Staibano S, et al. Dermatoscopic pitfalls in differentiat- ing pigmented Spitz naevi from cutaneous melanomas. Br J Dermatol 1999;141:788- 93. 7. Ferrara G, Argenziano G, Soyer HP, et al. Dermoscopic and histopathologic diagno- sis of equivocal melanocytic skin lesions: an interdisciplinary study on 107 cases. Cancer 2002;95:1094-100. 8. Ferrara G, Argenziano G, Soyer HP, et al. Histopathologic interobserver agreement on the diagnosis of melanocytic skin lesions with equivocal dermoscopic fea- tures: a pilot study. Tumori 2000;86:445-9. Case Report No n- co mm er cia l u se on ly