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Clinical Dermatology

Diagnostic spectrum of nodular melanoma

Review, 75 - 81
doi: 10.11138/cderm/2016.4.3.075
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Nodular melanoma represents 10 to 30% of all melanomas and circa 50% of those with a Breslow thickness greater than 2 mm. The main cause of death among malignant cutaneous tumors, it presents a high metastatic potential even in the early growth stages, making an early diagnosis fundamental.
It is more common in men than in women, its onset is in later age, in any part of the body, more often on the neck and head.
Due to its clinical characteristics (symmetrical, nodular, amelanotic/hypomelanotic or highly pigmented lesion) nodular melanoma is difficult to diagnose with the ABCD rule (Asymmetry, irregular Borders, Color variation and Diameter). For this reason it is preferred to use the EFG rule which takes into consideration Elevation, Firmness and rapid Growth pattern.
Histologically, nodular melanoma is characterized by the lacking of atypical melanocytes in the epidermis (up to 3 crests) beyond the lateral margins of the malignant dermal cellular component, with theca cells and/or confluent aggregates without maturation phenomena.
The dermoscopic structures mainly related to nodular melanoma are asymmetry of the pigmentation pattern, blue-white veil, blue-black areas, milky red areas, irregular dots and globules, atypical vascular pattern.
Recently reflectance confocal microscopy has permitted a close dermoscopic-confocal correlation of melanocytic and non-melanocytic skin lesions. RCM features of nodular melanoma show atrophic or thin epidermis, sheet-like structures at the dermo-epidermal junction and the presence of single or variable-in-size clusters of atypical melanocytes in the upper dermis in proximity or overlapping enlarged and convoluted vessels.
In the diagnostic challenge of nodular melanoma, integration between clinical parameters and noninvasive skin techniques are needed to warranty a correct evaluation of pigmented, hypopigmented or achromic nodular lesion.

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