“Lambs” in wolves’ clothing: when basal cell carcinoma mimics melanoma, but it is detected by the use of reflectance confocal microscopy

Background Basal cell carcinoma (BCC) is the most frequent non-melanoma skin cancer. There are some cases in which clinical and dermoscopic examinations do not allow to formulate a unique diagnosis and in particular can be difficult the differential diagnosis with melanoma. Reflectance confocal microscopy (RCM) is a non-invasive technology, which allows an in vivo imaging of the skin with high resolution. Objectives We addressed our research to evaluate the reliability of the well-known RCM criteria for classic BCCs in a group of lesions with atypical dermoscopy presentation, possibly mimicking melanoma. Methods We retrospectively analyzed at RCM excised lesions presenting in dermoscopy ≥1 score at revisited 7-point checklist. The study population consisted of 177 cases showing no melanocytic RCM findings. Lesions were investigated for distinct non-melanocytic RCM features, while blinded from histopathology. Histopathology matching was performed before statistical analysis. Results Among the lesions classified at RCM with no-melanocytic characteristics, we recognized 34 cases, histopathological confirmed as BCCs (21 nodular BCCs and 13 superficial BCCs) and 143 cases classified as other lesions (DFs, SebKs, SCCs and others). The main features of nBCCs (with histopathological confirm) at RCM are peritumoral clefts (20/21 95,2%; p=0,037), peripheral palisading (19/21 90,5%; p=0,001), increased vascularization (20/21 95,2%; p=0,004). In sBCCs we found mild keratinocytic atypia (13/13 100%; p=<0,001), solar elastosis (12/13 92,3%; p=0,002), cords connected to epidermidis (9/13 69,2%; p=<0,001). Dendritic structures, nests of basaloid cells, inflammatory infiltrate can be seen in all tumors. Conclusions RCM classification proved high agreement with histopathology for BCCs with atypical dermoscopy presentations, allowing an early differential diagnosis and even identification of BCCs subtypes. RCM features in this group of lesions were similar to those described for typical cases of BCCs, and may drive clinicians decisions, helped them in the recognition of melanocytic and non melanocytic lesions, increasing the rate of accurate diagnoses and allowing better therapeutic management

Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review

Invasive bacterial infections are a leading cause of morbidity and mortality after liver transplant (LT), especially during the first months after LT, and infections due to multi-drug-resistant organisms (MDRO) are increasing in this setting. Most of the infections in patients in intensive care unit arise from the endogenous microflora and, for this reason, pre-LT MDRO rectal colonization is a risk factor for developing MDRO infections in the post-LT. Moreover, the transplanted liver may carry an increased risk of MDRO infections due to organ transportation and preservation, to donor intensive care unit stay and previous antibiotic exposure. To date, little evidence is available about how MDRO pre-LT colonization in donors and recipients should address LT preventive and antibiotic prophylactic strategies, in order to reduce MDRO infections in the post-LT period. The present review provided an extensive overview of the recent literature on these topics, with the aim to offer a comprehensive insight about the epidemiology of MDRO colonization and infections in adult LT recipients, donor-derived MDRO infections, possible surveillance, and prophylactic strategies to reduce post-LT MDRO infections

Dermoscopy of melanoma according to different body sites: Head and neck, trunk, limbs, nail, mucosal and acral

Effective cancer screening detects early-stage tumours, leading to a lower incidence of late-stage disease over time. Dermoscopy is the gold standard for skin cancer diagnosis as diagnostic accuracy is improved compared to naked eye examinations. As melanoma dermoscopic features are often body site specific, awareness of common features according to their location is imperative for improved melanoma diagnostic accuracy. Several criteria have been identified according to the anatomical location of the melanoma. This review provides a comprehensive and contemporary review of dermoscopic melanoma criteria according to specific body sites, including frequently observed melanoma of the head/neck, trunk and limbs and special site melanomas, located on the nail, mucosal and acral region

Seborrheic keratoses mimicking melanoma unveiled by in vivo reflectance confocal microscopy

Background: Seborrheic keratoses (SebK) with atypical dermoscopy presentation are increasingly reported. These lesions do not exhibit typical dermoscopy features of SebK and sometimes mimic melanoma, thus complicating the differential diagnosis. Reflectance confocal microscopy (RCM) is a non-invasive tool, which allows an in vivo imaging of the skin. Objective: To evaluate the agreement between RCM classification and histological diagnoses, and the reliability of well-known RCM criteria for SebK in the identification of SebK with atypical dermoscopy presentation. Methodology: We retrospectively analysed at RCM excised lesions presenting in dermoscopy 651 score at revisited 7-point checklist. The study population consisted of cases showing no melanocytic RCM findings. Lesions were investigated for distinct non-melanocytic RCM features, blinded from histopathology diagnoses. Histopathology matching was then performed before statistical analysis. Results: The study consisted of 117 cases, classified at RCM as SebK (71 cases), dermatofibroma (DF; 18 cases), basal cell carcinoma (BCC; 13 cases), squamous cell carcinoma (SCC; 2 cases), and \u201cnon specific\u201d (13 cases). Overall K strength of agreement at histopathology matching proved 0.76. Of the 71 cases classified at RCM with SebK, agreement was achieved in 97%. Conclusions: RCM classification proved high agreement with histopathology for SebK with atypical dermoscopy presentations, allowing an early differential diagnosis. RCM features in this group of lesions were similar to those described for typical cases of SebK, and may assist clinician therapy decision making, whilst avoiding unnecessary excisions

Delay in cutaneous squamous cell carcinoma diagnosis due to interrupted services is associated with worse prognoses and modified surgical approaches

Background: The delayed diagnosis of skin tumors is associated with a worsened prognosis. The impact of the interruption of clinical and surgical health services during the COVID-19 pandemic lockdowns has been documented among many pathologies. The impact of delayed diagnoses on patients with cutaneous squamous cell carcinomas (cSCCs) is poorly defined. Objective: To compare patient and lesion characteristics and the surgical management of excised cSCCs prior to the pandemic shutdown of services (2018–2019) with the phase following the pandemic’s second wave (2021–2022). Methods: An observational, single-center, cross-sectional study of 416 surgically excised cSCCs over the course of two years was performed. Only patients with histologically confirmed cSCC were enrolled. Data collection included patient demographics and lesion characteristics, time to surgery, surgical approach, and histological data. Results: More cSCC lesions were excised prior to the interruption of services (n = 312 vs. n = 186). Lesions were significantly larger (1.7 ± 1.2 vs. 2.1 ± 1.5 cm; p = 0.006) and more invasive (52% vs. 89%; p < 0.001), in the period 2021–2022. Surgical reconstructive techniques were significantly different (p = 0.001). Metastatic involvement was confirmed in three subjects (one in 2018–2019 and two in 2021–2022). There were no significant differences in the time to surgery or patient characteristics. Multivariable regression analysis identified a 4.7-times higher risk of tumor invasion (OR 4.69, 95%CI 2.55–8.16, p < 0.001), a two-times higher chance of dermo-epidermal grafts (OR 2.06, 95%CI 1.09–3.88, p = 0.025), and a 3.2-times higher risk of positive surgical margins (OR 3.21, 95%CI 1.44–7.17, p = 0.004). Conclusions: Diagnostic delays of cutaneous SCCs associated with reduced patient access to clinical and diagnostic services are associated with a 4.7-times increased risk of more severe invasion, a three-times increased risk of positive surgical margins, and a significant impact on surgical management, compared to the pre-pandemic period. Comparable patient cohort characteristics and time to surgery remained unchanged

De Novo Skin Neoplasms in Liver-Transplanted Patients: Single-Center Prospective Evaluation of 105 Cases

Background and Objectives: Solid-organ transplant recipients (SOTRs) are notably considered at risk for developing cutaneous malignancies. However, most of the existing literature is focused on kidney transplant-related non-melanoma skin cancers (NMSCs). Conflicting data have been published so far on NMSC incidence among liver transplant recipients (LTRs), and whether LTRs really should be considered at lower risk remains controversial. The aim of the present study was to prospectively collect data on the incidence of cutaneous neoplasms in an LTR cohort. Materials and Methods: All LTRs transplanted at the Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit of Modena University Hospital from October 2015 to June 2021 underwent a post-transplant periodic skin check at the Dermatology Unit according to our institutional integrated care pathway. Data on the presence of cutaneous malignant and premalignant lesions were collected at every timepoint. Results: A total of 105 patients were enrolled in the present study. Nearly 15% of the patients developed cutaneous cancerous and/or precancerous lesions during the follow-up period. Almost half of the skin cancerous lesions were basal cell carcinomas. Actinic keratoses (AKs) were observed in six patients. Four patients developed in situ squamous cell carcinomas, and one patient was diagnosed with stage I malignant melanoma. Otherwise, well-established risk factors for the occurrence of skin tumors, such as skin phototype, cumulative sun exposure, and familial history of cutaneous neoplasms, seemed to have no direct impact on skin cancer occurrence in our cohort, as well as an immunosuppressive regimen and the occurrence of non-cutaneous neoplasms. Conclusions: Close dermatological follow-up is crucial for LTRs, and shared protocols of regular skin checks in this particular subset of patients are needed in transplant centers

Lesions mimicking melanoma at dermoscopy confirmed basal cell carcinoma: evaluation with reflectance confocal microscopy

Background Atypical basal cell carcinoma (BCC), characterized by equivocal dermoscopic features typical of malignant melanoma (MM), can be difficult to diagnose. Reflectance confocal microscopy (RCM) enables in vivo imaging at nearly histological resolution. Objectives To evaluate BCCs mimicking melanoma at dermoscopy according to well-known RCM criteria for typical BCCs, and identify discriminate RCM parameters for superficial (sBCCs) and nonsuperficial BCCs (nsBCCs). Material and Methods A retrospective analysis of consecutive patients, evaluated with RCM, selecting excised lesions classified at dermoscopy with ≥1 score from the revisited seven-point checklist, mimicking melanoma, registered between 2010 - 2016. Lesions without RCM melanocytic parameters, were investigated by operators blinded to histopathology diagnoses. Cluster analysis identified BCC sub-classifications. Results Of 178 atypical lesions, 34 lesions were diagnosed BCC with RCM, and diagnoses were confirmed with histopathology. Dermoscopic features observed atypical network (55.9%), and regressions structures (35.5%) associated with sBCCs, and atypical vascular pattern (58.8%) and irregular blotches (58.8%) with nsBCC. Hierarchical cluster analysis identified 2 clusters: cluster 1 (100% sBCCs) was characterized by the presence of cords connected to the epidermis (90%, p<0.001), tumor islands located in the epidermis (100%, p<0.001), smaller vascular diameter (100%, p<0.001) and solar elastosis (90%, p=0.017) and cluster 2 (nsBCCs 85%) by the dermic location of tumor islands (87.5%, p<0.001) with branch-like structures (70.8%, p= 0.007) and surrounding collagen (83.3%, p=0.012), peripheral palisading (83.3%, p=0.012), and coiled vascular morphology (79.2%, p<0.001) with larger vascular diameter (50%, p<0.001). Conclusions RCM is able to diagnose BCCs mimicking melanoma at dermoscopy and seems able to identify sBCCs and nsBCCs. Therefore, the use of RCM may assist in optimizing therapeutic management of these equivocal lesions

Lesions mimicking melanoma at dermoscopy confirmed basal cell carcinomas: evaluation with reflectance confocal microscopy

Background: Atypical basal cell carcinoma (BCC), characterized by equivocal dermoscopic features typical of malignant melanoma (MM), can be difficult to diagnose. Reflectance confocal microscopy (RCM) enables in vivo imaging at nearly histological resolution. Objectives: To evaluate BCCs mimicking melanoma at dermoscopy according to well-known RCM criteria for typical BCCs, and identify discriminate RCM parameters for superficial (sBCCs) and nonsuperficial BCCs (nsBCCs). Material and Methods: A retrospective analysis of consecutive patients, evaluated with RCM, selecting excised lesions classified at dermoscopy with ≥1 score from the revisited seven-point checklist, mimicking melanoma, registered between 2010 - 2016. Lesions without RCM melanocytic parameters, were investigated by operators blinded to histopathology diagnoses. Cluster analysis identified BCC sub-classifications. Results: Of 178 atypical lesions, 34 lesions were diagnosed BCC with RCM, and diagnoses were confirmed with histopathology. Dermoscopic features observed atypical network (55.9%), and regressions structures (35.5%) associated with sBCCs, and atypical vascular pattern (58.8%) and irregular blotches (58.8%) with nsBCC. Hierarchical cluster analysis identified 2 clusters: cluster 1 (100% sBCCs) was characterized by the presence of cords connected to the epidermis (90%, p<0.001), tumor islands located in the epidermis (100%, p<0.001), smaller vascular diameter (100%, p<0.001) and solar elastosis (90%, p=0.017) and cluster 2 (nsBCCs 85%) by the dermic location of tumor islands (87.5%, p<0.001) with branch-like structures (70.8%, p= 0.007) and surrounding collagen (83.3%, p=0.012), peripheral palisading (83.3%, p=0.012), and coiled vascular morphology (79.2%, p<0.001) with larger vascular diameter (50%, p<0.001). Conclusions: RCM is able to diagnose BCCs mimicking melanoma at dermoscopy and seems able to identify sBCCs and nsBCCs. Therefore, the use of RCM may assist in optimizing therapeutic management of these equivocal lesions

Lentigo maligna and lentigo maligna melanoma in vivo differentiation with dermoscopy and reflectance confocal microscopy. a retrospective, multicentre study

IntroductionDermoscopic predictors of lentigo maligna (LM) and lentigo maligna melanoma (LMM) have been recently reported, but these have not been reported in reflectance confocal microscopy (RCM). Objectives(i) To validate dermoscopic predictors for LM/LMM, (ii) to identify RCM patterns in LM and LMM, and (iii) correlations between dermoscopic and RCM features in LM and LMM. Materials and MethodsA retrospective, multicentre study of consecutive lesions with histologically proven LM or LMM subtypes of the head and face, with complete sets of dermoscopic and RCM images. ResultsA total of 180 lesions were included (n = 40 LMM). Previously reported differential dermoscopic features for LM subtypes were confirmed. Other features significantly associated with LMM diagnosis included irregular hyperpigmented areas, shiny white streaks, atypical vessels and light brown colour at dermoscopy and medusa head-like structures, dermal nests and nucleated cells within the papillae at RCM (p < 0.05). Correlations among LM lesions between dermoscopic and RCM features included brown to-grey dots and atypical cells (epidermis), grey colour and inflammation and obliterated follicles and medusa head-like structures. Among LMM lesions, significant correlations included obliterated follicles with folliculotropism, both irregular hyperpigmented areas and irregular blotches with widespread atypical cell distribution (epidermis), dermal nests and nucleated cells within the papillae (dermis). Irregular blotches were also associated with medusa head-like structures (dermal epidermal junction [DEJ]). ConclusionsDermoscopic and RCM features can assist in the in vivo identification of LM and LMM and many are correlated. RCM three-dimensional analysis of skin layers allows the identification of invasive components in the DEJ and dermis

Vancomycin resistant enterococcus risk factors for hospital colonization in hematological patients: a matched case-control study

BackgroundVancomycin-resistant enterococcus (VRE) was the fastest growing pathogen in Europe in 2022 (+ 21%) but its clinical relevance is still unclear. We aim to identify risk factors for acquired VRE rectal colonization in hematological patients and evaluate the clinical impact of VRE colonization on subsequent infection, and 30- and 90-day overall mortality rates, compared to a matched control group.MethodsA retrospective, single center, case-control matched study (ratio 1:1) was conducted in a hematological department from January 2017 to December 2020. Case patients with nosocomial isolation of VRE from rectal swab screening (>= 48 h) were matched to controls by age, sex, ethnicity, and hematologic disease. Univariate and multivariate logistic regression compared risk factors for colonization.ResultsA total of 83 cases were matched with 83 controls. Risk factors for VRE colonization were febrile neutropenia, bone marrow transplant, central venous catheter, bedsores, reduced mobility, altered bowel habits, cachexia, previous hospitalization and antibiotic treatments before and during hospitalization. VRE bacteraemia and Clostridioides difficile infection (CDI) occurred more frequently among cases without any impact on 30 and 90-days overall mortality. Vancomycin administration and altered bowel habits were the only independent risk factors for VRE colonization at multivariate analysis (OR: 3.53 and 3.1; respectively).ConclusionsAntimicrobial stewardship strategies to reduce inappropriate Gram-positive coverage in hematological patients is urgently required, as independent risk factors for VRE nosocomial colonization identified in this study include any use of vancomycin and altered bowel habits. VRE colonization and infection did not influence 30- and 90-day mortality. There was a strong correlation between CDI and VRE, which deserves further investigation to target new therapeutic approaches