Advances in Dermoscopy

Question 1

Describe how the classification of white lines has changed wrt BCC

Answer 1

They are thicker than white lines in melanoma.
Therefore described as white shiny strands
OR
white shiny blotches

(White lines are common in BCC. May be present in > 30% )

Question 2

Describe how the classification of white lines has changed wrt Melanoma

Answer 2

They are thinner than white lines in BCC.

Therefore described as
white shiny streaks or white shiny lines.

Question 3

What are May globules in BCC

Answer 3

White clods

Rare - only around 3% BCC
Eccentric/ scattered. Cf white clods in sebaceous hyperplasia.

Question 4

What is the earliest sign of melanoma in an acquired nevus.

Answer 4

Irregular hyperpigmented areas

Scattered brown or black color

Question 5

What percentage of melanomas develop de novo?

Answer 5

> 70%

close to 70%

Question 6

What percentage of melanomas develop on a pre-existing nevus?

Answer 6

< 30%

close to 30%

Question 7

What is the primary clue to nevus associated melanoma?

(Small/ medium CMN)

Answer 7

Inverse network.

(Brown globules surrounded by white color. )

Question 8

What is the secondary clue to nevus associated melanoma?

(Small/ medium CMN)

Answer 8

Grey polygonal lines developing inside the nevus.

Question 9

Inverse network, evenly distributed is found in which type of nevus?

Answer 9

Spitzoid nevus

Question 10

What are the 3 types of spitzoid nevi?

Answer 10

1. Starburst
2. dotted vessels
3. globules with reticular depigmentation (inverse network)

Question 11

What are the two pathways to melanoma associated nevus?

Answer 11

1. Develops within the nevus.
2. Develops adjacent to the nevus.

Question 12

Why is dermoscopy not helpful in the diagnosis of melanoma in giant congenital nevi?

Answer 12

Melanoma develops deep in the dermis.

Question 13

A symmetrical lesion with peripheral rim of globules (symmetrical) should be interpreted according to the age of the patient. True/False?

Answer 13

False

In a large database 100% of lesions that meet these criteria are benign.

Question 14

Features distinguishing melanosis from melanoma of genitals. Name 4.

Answer 14

Age
Flat vs raised
Pattern
Color

Question 15

Features associated with melanosis of genitalia. Name 3

Answer 15

Young age
Flat lesion
Parallel lines

Question 16

Features associated with melanoma of genitals

Answer 16

Older age
Raised lesion’
Structureless
Blue and red color

Question 17

Revision. Features of lentigo maligna on the face. List 4.

Answer 17

1. Gray dots/clods
2. Asymmetric follicular openings
3. angulated lines (rhomboid structures)
4. Obliteration of the follicles.

Question 18

Imiquimod as adjuvant therapy for lentigo maligna. What is the cure rate?

Answer 18

95%

Question 19

Imiquimod as adjuvant therapy for lentigo maligna. What is the strength/ duration of therapy.

Answer 19

5% 7 days per week for up to 7 weeks.

Question 20

Is radiotherapy an effective alternative treatment for lentigo maligna. Yes/No

Answer 20

Yes

Question 21

Approach to Acral lesions

Answer 21

1. Is there a clear parallel furrow pattern throughout the lesion?
   If not:
2. Is the lesion >= 7 mm? Then excise
3. Is there asymmetry of structure and color? Then excise.

Question 22

Ddx of parallel ridge pattern

Answer 22

1. Melanoma
2. Subcorneal hemorrhage

Question 23

What is a reasonable follow up interval for an acral lesion?

Answer 23

3/12

Question 24

What is a reasonable follow up time for a nail lesion?

Answer 24

6-12/12

Question 25

Approach to assessing melanonychia striata. Name the important steps.

Answer 25

1. Is this is hemorrhage 2. Is only one nail involved, or multiple nails. 3. If only one nail involved involved, assess the color of the band. Brown or Grey. 4. If the band is brown, distinguish nevus from melanoma.

Question 26

Approach to assessing melanonychia striata. What is the significance of grey bands?

Answer 26

Benign lesion Lentigo of nail plate Reactive pigment

Question 27

Approach to assessing melanonychia striata. What is the significance of brown bands?

Answer 27

Associated with melanocytic tumors.

Question 28

Approach to assessing melanonychia striata. What are the features of melanoma.

Answer 28

Irregular bands of pigmentation. (Irregular spacing of bands and variation of color) Hutchinson's sign. (Pigmentation of peri-ungual skin/ proximal nail fold) Micro-Hutchinson sign. Pigmentation see only with dermoscope.

Question 29

Hutchinson's sign is suggestive of melanoma with one exception.

Answer 29

Congenital nevus of the nail in a child.

Question 30

WRT melanonychia striata, what is the significance of triangular shape of nail band.

Answer 30

The nevus is growing.

Question 31

WRT melanonychia striata, what is the significance of wide band. (> 50%)

Answer 31

Very likely to be a melanoma. (Except CMN)

Question 32

What is the only nevus that does not result in coloration of the nail plate itself.

Answer 32

Blue nevus. This arises deep in the dermis.

Question 33

Name 4 causes of gray band in the nail.

Answer 33

1. Nail Lentigo 2. Ethnic pigmentation. 3. Drugs. 4. Laugier-Hunziker

Question 34

What is the differentia diagnosis when only 1 nail is pigmented. Name 4 conditions.

Answer 34

1. Nevus, 2. melanoma, 3. lentigo, 4. reactive pigmentation.

Question 35

When is amputation required for nail melanoma

Answer 35

Lesions thicker than 1 mm. Tendency is for more conservative management.

Question 36

Are acral and nail melanoma easy to diagnose pathologically at an early stage.

Answer 36

No. The pathologist may report atypical nevus or atypical melanocytic proliferation.

Question 37

Is follow up of nail melanoma a reasonable strategy?

Answer 37

Yes Owing to limitations of histopathology in the setting, 9 month follow up is a reasonable option.

Question 38

What percentage of patients with "ugly mole" syndrome will develop melanoma over time?

Answer 38

3%

Question 39

What percentage of patients with "ugly mole" syndrome will develop melanoma over time if they have had a prior melanoma?

Answer 39

10%

Question 40

Which patients are appropriate for digital dermatoscopic monitoring? Name 5 categories.

Answer 40

1. Patients with > 60 melanocytic nevi. 2. Patients with CDKN2A mutation. (Independent from the total nevus count.) 3. Patients with > 40 melanocytic nevi, and personal history of melanoma. 4. Patients wth > 40 melanocytic nevi and red hair and/ or MC1R mutation. 5. Patients with > 40 melanocytic nevi and organ transplant.