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Two step algorithm (melanocytic vs non-melanocytic) Flashcards

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1
Q

What is the main purpose of the 2-step algorithm?

A

Avoid missing the diagnosis of melanoma

Designed to maximize the sensitivity for melanoma detection

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2
Q

Limitations of the 2-step algorithm

A

Designed to evaluate lesions on glabrous & nonglabrous skin only

Not intended for evaluation of nail,mucosa, hair abnormalities

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3
Q

Algorithm for the differentiation btw melanocytic & nonmelanocytic lesions

A
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4
Q

1st step in 2-step algorithm

A

Decide whether a lesion is of melanocytic or nonmelanocytic origin

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5
Q

1st step is composed of how many levels?

A

7 levels

Each of which requires the
clinician to search for specific structures and criteria

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6
Q

Name the 7 decision levels of the first step

A

Criteria for

  • Level 1: Melanocytic lesions
  • Level 2: BCC
  • Level 3: SKs
  • Level 4: Vascular lesions
  • Level 5: Specific blood vessels for nonmelanocytic neoplasms
  • Level 6: Specific blood vessels for melanocytic lesions
  • Level 7: Structureless
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7
Q

All lesions in level 7 are considered…?

A

Melanocytic by default

Melanoma needs to be considered in the DDx

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8
Q

2nd step in the 2-step algorithm

A

Determine whether the presumed melanocytic lesion from step 1

is benign, suspect, or malignant

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9
Q

Two-step procedure for the differential diagnosis of pigmented lesions

A
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10
Q

What does the 1st level of step 1 consist of?

A

Criteria for melanocytic lesions

  • Pigment network
  • branched streaks (e.g., atypical network)
  • streaks (i.e., radial streaming and pseudopods)
  • negative network
  • aggregated globules
  • homogenous blue pigmentation
  • pseudonetwork (face)
  • parallel pattern (palms, soles, and mucosa)
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11
Q

If any of the criteria in level 1 are met, what is the BNS?

A

Lesion is considered of melanocytic origin

Proceed directly to the 2nd step of the 2-step algorithm

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12
Q

Name one major exception of 1st level

A

Dermatofibroma

Delicate peripheral network with a central scar-like area

(as seen in NPD)

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13
Q

How to differentiate a blue nevus from other lesions

A

Blue-white veil that’s covers the ENTIRE lesion

in a HOMOGENOUS manner (NPD)

ps: in PD blue nevus reveal different shades or hues of blue

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14
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Typical regular pn (Level 1)

Thinning out toward the periphery

Junctional nevus

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15
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Atypical pn

Branched streaks

Dysplastic nevus

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16
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Globular architecture

multiple round & ovoid globules

Compound nevus

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17
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Homogenous blue veil pigmentation

that covers the ENTIRE lesion

Blue nevus

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18
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Typical regular pseudonetwork

Compound nevus of the face

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19
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Lattice-like pattern

variation of the parallel furrow pattern

Junctional nevus, palm

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20
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Irregular confluent bluish-whitish pigmentation

does NOT occupy the entire surface area of the lesion

Malignant melanoma

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21
Q

None of the criteria of level 1 are met, BNS?

A

Proceed to level 2

Criteria for BCC

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22
Q

Name the criteria for BCC

A
  1. ​Arborizing blood vessels (telangiectasias)
  2. Leaf-like areas
  3. Large blue-gray ovoid nests
  4. Multiple blue-gray non-aggregated globules
  5. Spoke-wheel-like structures
  6. Shiny white areas
  7. Ulceration
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23
Q

Condition under which, presence of level 2 criteria are ^ suggestive of BCC?

A

Absence of pigment network

NEVER SKIP level 1

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24
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Arborizing telangiectasia (arrows)

Ulceration (arrowheads)

Multiple leaf-like areas (asterisks)

pBCC

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25
Describe the major dermoscopic finding in this lesion Dx?
Multiple blue-gray ovoid nests (arrows) Leaf-like areas Telangiectasia (left part) Nodular pBCC
26
Describe the major dermoscopic findings in this lesion Dx?
Multiple blue-gray non-aggregated globules (arrows) blue-gray ovoid nests ulceration (asterisks) arborized telan- giectasia (arrowheads) pBCC
27
If none of the criteria of level 2 are met, BNS?
Proceed to level 3 Criteria for SKs
28
Name the criteria for SKs
1. Multiple milia-like cysts 2. Comedo-like openings 3. Crypts 4. Moth-eaten borders 5. Network-like structures 6. Fissures and ridges (aka gyri & sulci) 7. Fingerprint-like structures
29
Does presence of milia cysts equate Dx of SK?
No * DDx: 1. SKs 2. BCC 3. Melanocytic nevi (especially congenital type) If 2,3 are excluded then milia cysts are a diagnostic criterion
30
Describe the major dermoscopic finding in this lesion Dx?
multiple milia- like cysts (arrows) comedo-like openings (asterisks) network-like structures (dotted areas) at the periphery pSK
31
How to DDx a SK from a melanocytic lesion?
Examine the lesion on side-lighting =\> cerebriform appearance by gyri/sulci will be more evident & easier to DD from pigment network
32
Describe the major dermoscopic findings in this lesion Dx?
Multiple comedo-like openings crypt in the right part of the lesion (arrows) pSK
33
Describe the major dermoscopic findings in this lesion Dx?
moth-eaten border (arrows) multiple milia-like cysts (aster- isks) pSK , face
34
Describe the major dermoscopic findings in this lesion Dx?
fat finger-like structures (arrows) multiple milia-like cysts SK, face
35
If none of the SK criteria are seen, BNS?
Proceed to level 4 Criteria for vascular lesions
36
Name the criteria for vascular lesions , DDx?
Presence of red, maroon, or red-blue to black lacunae * DDx: 1. Hemangioma 2. Angiokeratoma
37
Describe the major dermoscopic findings in this lesion Dx?
Multiple dark red lacunae Hemangioma
38
If the criteria for levels 1–4 have not been satisfied, BNS?
Proceed to level 5 Specific Blood Vessels in Nonmelanocytic Lesions
39
Name some specific patterns of blood vessels seen in hypo- /non- melanocytic lesions
* Hairpin vessels with whitish halo * Glomerular vessels, at the periphery * Serpiginous vessels * Crown vessels
40
Regular vs irregular DDx of hairpin vessels (Vessels that double back on themselves, seen as loops, surrounded by a hypopigmented halo)
* Regular: SK * Irregular: Melanoma, Spitz nevus, keratoacanthoma
41
DDx of crown vessels (barely branching peripheral vessels that do not cross the center of the lesion)
* Sebaceous hyperplasia * Molluscum contagiosum
42
Vessel morphology
43
DDx based on vessel morphology
44
Describe the major dermoscopic findings in this lesion Dx?
Elongated hairpin blood vessels with whitish halo central ulceration with blood crusts central keratotic plug -- Keratoacanthoma
45
Describe the major dermoscopic findings in this lesion Dx?
Glomerular (coiled) vessels Clustered vascular pattern hyperkeratosis (surface scale) non-pigmented Bowen's disease
46
DDx of glomerular vessels
Bowen's disease SCC
47
Describe the major dermoscopic findings in this lesion Dx?
"String of pearls" vessel pattern Clear cell acanthoma
48
Progression model of keratinocytes skin cancer
49
Describe the major dermoscopic finding in this lesion Dx?
Crown vessels Molluscum contagiosum
50
If the criteria for levels 1–5 have not been satisfied, BNS?
Proceed to level 6 Search for specific vessels in melanocytic lesions
51
Name some specific patterns of vessels in melanocytic lesions
* Comma- shaped blood vessels, hallmark of intradermal nevi * Pinpoint or dotted * Corkscrew vessels * Polymorphic vessels
52
Polymorphic vessels DDx? (when two or more types of vessel morphologies are detected)
* Melanoma (serpentine + dotted) * SCC (hairpin + glomerular)
53
Comma-shaped vessels DDx
* Dermal nevus (!!!) * Compound, congenital nevi * BCC, melanoma (less often)
54
Corkscrew/tortuous vessels DDx
* Melanoma (nodular , desmoplastic) * Melanoma metastasis * BCC
55
Arborizing vessels DDx
* BCC (hallmark) * Nodular melanoma * Juvenile xanthogranuloma * Merkel cell carcinoma * Intradermal nevi
56
Milky red globules/areas DDx
* Invasive melanoma (thick amelanotic melanoma) * Merkel CC (MCC) * BCC Pyogenic granuloma (PG)
57
Strawberry pattern DDx?
Nonpigmented facial AK
58
Name the blood vessel pattern and their DDx
1. Crown/radial: Senile sebaceous hyperplasia, Molluscum contagiosum, keratoacanthoma 2. Serpiginous: Clear cell acanthoma 3. Arborizing: BCC 4. Clustered: Bowen 5. Centered dots: Spitz nevi, amelanotic/hypomelanotic melanoma
59
Describe the major dermoscopic finding in this lesion Dx?
Comma-shaped vessels Dermal nevus
60
Describe the major dermoscopic finding in this lesion Dx?
Dotted vessels Melanoma
61
Describe the major dermoscopic findings in this lesion Dx?
Corkscrew/tortuous vessels (white arrowheads) linear irregular vessels (blue arrowheads) in a pink background Amelanotic/hypomelanotic nodular melanoma
62
Describe the major dermoscopic finding in this lesion Dx?
Hairpin vessels with whitish halo SK
63
Describe the major dermoscopic finding in this lesion Dx?
Glomerular vessels (regularly arranged) Bowen's disease
64
Describe the major dermoscopic findings in this lesion Dx?
Arborizing vessels BCC
65
Describe the major dermoscopic finding in this lesion Dx?
Pearls on a string or serpiginous pattern vessels Clear cell acanthoma
66
Describe the major dermoscopic finding in this lesion Dx?
Crown vessels Sebaceous hyperplasia
67
Describe the major dermoscopic finding in this lesion Dx?
Strawberry pattern Keratotic and plugging follicles with a reddish background caused by ^ superficial vascular volume Actinic keratosis
68
Describe the major dermoscopic finding in this lesion Dx?
Milky red areas/globules Thick hypomelanotic melanoma
69
Describe the major dermoscopic finding in this lesion Dx?
Red‐purple lacunae Angiokeratoma
70
Describe the major dermoscopic finding in this lesion Dx?
Strawberry pattern pink/red pseudonetwork with blurry vessels btw hair follicle openings filled with keratotic plugs Non-pigmented facial AK
71
Milky red color represents...?
* ^ vascular volume * reflection of neoangiogenesis
72
If the criteria for levels 1–6 have not been satisfied, BNS?
Proceed to level 7 Search for structureless lesions
73
Management of level 7 lesions
Biopsy or short-term mole monitoring You MUST avoid missing melanomas (worst case scenario)
74
Name some possible patterns of level 7 lesions
* Structureless/ featureless * Fine dots * Peppering * Blue-white veil * Crystalline structure * Blotches
75
Describe the major dermoscopic finding in this lesion Dx?
Blue-white veil that does NOT cover the entire lesion Malignant melanoma
76
Which level of lesions from step-1 can be subjected to the 2nd step of the 2-step algorithm?
* Level 1 (melanocytic lesions) * Level 6 * Level 7

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