reflectance confocal microscopy (RCM) is a noninvasive high-resolution skin imaging tool that has become an important adjunct to clinical exam, dermoscopy and histopathology assessment, in the ...diagnosis and management of melanoma. RCM generates a horizontal view of the skin, whereby cellular and subcellular (e.g., nuclei, melanophages, collagen) structures, to the level of the upper dermis, are projected onto a screen at near-histological resolution. Morphologic descriptors, standardized terminology, and diagnostic algorithms are well established for the RCM assessment of melanoma, melanocytic, and nonmelanocytic lesions. Clinical applications of RCM in melanoma are broad and include diagnosis, assessment of large lesions on cosmetically sensitive areas, directing areas to biopsy, delineating margins prior to surgery, detecting response to treatment and assessing recurrence. This review will provide an overview of RCM technology, findings by melanoma subtype, clinical applications, as well as explore the accuracy of RCM for melanoma diagnosis, pitfalls and emerging uses of this technology
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The germline BAP1 (BRCA1-associated protein-1) mutation and associated cancer pre-disposition syndrome was first described in 2011. Since then, physicians have considered this diagnosis for patients ...with a characteristic personal or family history of BAP1-associated tumours (mainly uveal and cutaneous melanoma, pleural/peritoneal mesothelioma, renal cell carcinoma and BAP1-deficient melanocytic lesions). However, a positive germline BAP1 mutation detection creates significant uncertainty in terms of appropriate cancer surveillance. A number of groups have proposed surveillance plans but important management dilemmas remain unresolved. The lifetime risk of developing cancer is not known and it is not clear if surveillance would lead to detecting cancer at an earlier stage or change survival outcomes. A consensus monitoring strategy was initially proposed at the Melanoma Institute Australia Melanoma Multidisciplinary Team meeting and later discussed with specialists in the field of cancer genetics, pathology, radiology, medical oncology, ophthalmology and dermatology. The objectives were to facilitate early diagnosis, incorporating where possible, clinically based and low/non-ionising radiation imaging modalities, applying the principles of a good screening test and a multidisciplinary focus.
•A cancer surveillance plan is proposed for germline BAP1 mutation cohorts in the context of discussion about the dilemmas associated with screening this group.•Detailed descriptions of proposed surveillance for the five main tumour types, including radiological discussion, expanding on previous more generalised recommendations.•Broadest interdisciplinary expert collaboration to date, including clinical cancer genetics, oncology, pathology, radiology, ophthalmology and dermatology.
Distinguishing lentigo maligna (LM) and lentigo maligna melanoma (LMM) from background pigmented non-melanoma lesions is challenging. The field of solar damage can obscure clinical assessment, and ...diagnostic ambiguities are created due to the overlap of the clinical features of LM with other benign lesions. Moreover, margin assessment on histology is limited by the resemblance between melanocytic hyperplasia of actinically damaged skin and scattered atypical melanocytes of LM/LMM. Dermoscopy has made a significant contribution but is often not sufficient for diagnosis and margin assessment. Confocal microscopy has become an important complementary tool in enhancing the management of these complex lesions.
Scope Varithena® is a recently approved commercially available drug/delivery unit that produces foam using 1% polidocanol for the management of varicose veins. The purpose of this review is to ...examine the benefits of foam sclerotherapy, features of the ideal foam sclerosant and the strengths and limitations of Varithena® in the context of current foam sclerotherapy practices. Method Electronic databases including PubMed, Medline (Ovid) SP as well as trial registries and product information sheets were searched using the keywords, 'Varithena', 'Varisolve', 'polidocanol endovenous microfoam', 'polidocanol' and/or 'foam sclerotherapy/sclerosant'. Articles published prior to 20 September 2016 were identified. Results Foam sclerosants have effectively replaced liquid agents due to their physiochemical properties resulting in better clinical outcomes. Medical practitioners commonly prepare sclerosant foam at the bedside by agitating liquid sclerosant with a gas such as room air, using techniques as described by Tessari or the double syringe method. Such physician-compounded foams are highly operator dependent producing inconsistent foams of different gas/liquid compositions, bubble size, foam behaviour and varied safety profiles. Varithena® overcomes the variability and inconsistencies of physician-compounded foam. However, Varithena® has limited applications due to its fixed sclerosant type and concentration, cost and lack of worldwide availability. Clinical trials of Varithena® have demonstrated efficacy and safety outcomes equivalent or better than physician-compounded foam but only in comparison to placebo alone. Conclusion Varithena® is a promising step towards the creation of an ideal sclerosant foam. Further assessment in independent randomised controlled clinical trials is required to establish the advantages of Varithena® over and above the current best practice physician-compounded foam.
V-raf murine sarcoma viral oncogene homolog B1 (BRAF) inhibitors have emerged as a promising targeted therapy for malignancies with BRAF mutations, particularly metastatic melanoma. However, ...granulomatous reactions (GRs), including sarcoidosis and sarcoid-like reactions, have been reported as a consequence of BRAF inhibition. It is important to adequately characterize these GRs, including cutaneous manifestations and systemic involvement, in order to guide investigations and management. A literature review was conducted to characterize the spectrum of GRs associated with BRAF inhibitors, identifying 55 reactions affecting 51 patients, with 37 reactions limited to cutaneous involvement. Further, a possible correlation with cancer response, mechanisms of granuloma formation, and a proposed workup and management approach for these GRs are presented.
Minocycline‐induced pigmentation (MIP) is an uncommon but well‐described adverse effect of oral minocycline treatment. MIP is clinically and histopathologically distinct from post‐sclerotherapy ...pigmentation. We report a case of a patient presenting with blackened skin overlying veins recently treated with endovenous laser and foam sclerotherapy. The patient was a 44‐year‐old male with systemic sclerosis who commenced minocycline for the treatment of rosacea 5 months prior. Histological examination of the discolored tissue and underlying vein revealed hemosiderin deposition in the dermis and pigmented macrophages within the sub‐endothelial layer of the vein wall with a staining pattern consistent with MIP. Venous tissue has not previously been reported in the literature as a target of minocycline pigmentation. Our patient preferred to control his rosacea by continuing to take minocycline. Follow‐up ultrasound examinations revealed the treated vessels to be fully occluded with no evidence of recanalization, residual flow or ongoing thrombophlebitis. Despite a good sclerotherapy outcome, the pigmentation did not subside over 2 years. This case demonstrates that oral minocycline may induce significant and potentially long‐term pigmentation in predisposed patients undergoing sclerotherapy.
Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell malignancy with features of both a myeloproliferative neoplasm and a myelodysplastic syndrome. We present a case of ...72‐year‐old man with CMML who presented with generalized hemorrhagic papules and plaques which on histopathology showed a peculiar infiltrate of atypical mature histiocytes. The immunohistochemical markers for Langerhans cells, indeterminate dendritic cells, and plasmacytoid dendritic cells were negative. Next generation sequencing performed on the paraffin block of the leg biopsy specimen revealed identical ASXL1, SRSF2, and KRAS mutations as seen in the CMML clone of the peripheral blood. Along with recent literature, this case illustrates the spectrum of histiocytic and dendritic cell proliferations in CMML, many of which may be clonally related to the hematopoietic malignancy.
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