Supplementary Material for: Similar but Different: How Reflectance Confocal Microscopy May Help in the Diagnosis of Pink Lesions

<strong><em>Background:</em></strong> Among skin neoplasms, solitary pink tumors represent challenging lesions in clinical practice since they can mimic melanocytic and nonmelanocytic lesions or even inflammatory ones. <b><i>Objective:</i></b> In this case series we described dermoscopic and confocal features of 2 couples of similar lesions in order to achieve the correct diagnosis and the best therapeutic approach. <b><i>Methods:</i></b> During clinical routine practice, 2 couples of clinically and dermoscopically similar lesions were examined by means of confocal microscopy. <b><i>Results:</i></b> All lesions revealed no clear-cut diagnostic features on dermoscopy. However, confocal microscopy revealed tumor islands with palisading cells and a dark clefting at the periphery in basal cell carcinomas. In the other “false twin” lesions, atypical cells and elongated junctional nests were observed and the diagnosis of amelanotic melanomas was rendered. <b><i>Conclusions:</i></b> In the current case series, the combined use of dermoscopy and reflectance confocal microscopy was an optimal workup for difficult-to-diagnose lesions such as pink tumors

Supplementary Material for: Unusual Dermoscopic Patterns of Seborrheic Keratosis

<b><i>Background:</i></b> Seborrheic keratoses (SKs) may sometimes mimic benign and malignant skin tumors, and a biopsy can be necessary in order to rule out malignancy. <b><i>Methods:</i></b> From the database of our pigmented lesion clinic, we evaluated the dermoscopic features of difficult-to-diagnose SKs that were biopsied between January 2010 and December 2014. <b><i>Results:</i></b> SKs represented 3.8% of all excised lesions (161/ 4,182). Specifically, 91 (56.5%) were excised to rule out melanoma, 63 (39.1%) to rule out squamous cell carcinoma and 7 (4.4%) to rule out basal cell carcinoma. The following 10 global dermoscopic patterns were identified: multicomponent (32; 19.9%); reticular (24; 14.9%), characterized by an irregular pigment network; bowenoid (21; 13.0%); hairpin (19; 11.8%); keratoacanthoma-like (16; 9.9%); blue-nevus-like (15; 9.3%); lichenoid (6; 3.7%); hyperkeratotic (6; 3.7%); clonal (5; 3.1%); spitzoid (5; 3.1%). Furthermore, 12 SKs (7.5%) were not included in any of such patterns (not classified). <b><i>Conclusion:</i></b> Our results are in line with previous studies highlighting the dermoscopic variability of SKs. Although excised SKs may be classified into 1 of 10 repetitive dermoscopic patterns, a biopsy remains mandatory for those that cannot be clearly differentiated from common skin malignancies

Supplementary Material for: False-Negative Cases on Confocal Microscopy Examination: A Retrospective Evaluation and Critical Reappraisal

<b><i>Background:</i></b> Confocal microscopy is a second-level examination for dermoscopically equivocal melanocytic lesions. However, the number of false-negative cases on confocal microscopy and the scenarios in which confocal microscopy may fail have not been fully elucidated. <b><i>Objective:</i></b> To calculate the percentage of false-negative melanomas upon reflectance confocal microscopy examination in a large series of cases. <b><i>Methods:</i></b> A retrospective analysis on 201 melanomas, evaluated for dermoscopic/confocal criteria of melanoma, was carried out. <b><i>Results:</i></b> Twenty-three melanomas out of 201 cases (11.4%) revealed a low 7-point checklist score. On confocal examination, 22 out of 23 lesions have been diagnosed correctly as melanomas. Only 1 lesion did not display melanoma features, neither upon dermoscopy nor upon confocal microscopy examination. Seven lesions out of 201 cases (3.5%) were judged as negative on confocal examination, even if 6 of them were diagnosed as melanomas by clinical and/or dermoscopic evaluation. After histopathological revision, these cases were grouped into 5 categories: (1) amelanotic melanoma (n = 1), (2) hyperkeratotic melanomas (n = 2), (3) lentiginous melanomas (n = 2), (4) melanoma with small pagetoid cells (n = 1), (5) spitzoid melanoma (n = 1). <b><i>Conclusion:</i></b> Confocal and dermoscopic examination, along with patient-related information and clinical history, can lead to an optimal patient management

Supplementary Material for: Clinical, Dermoscopic and Histopathological Features of Eccrine Poroid Neoplasms

<b><i>Background:</i></b> Eccrine poroma (EP) belongs to the group of benign adnexal tumors, but cases of eccrine porocarcinoma (EPC) arising on long-standing and untreated EP suggest a certain risk of malignant transformation. <b><i>Objectives:</i></b> To describe the clinical, dermoscopic and histopathologic features associated with different extremes in the spectrum of eccrine poroid neoplasms and to review the according literature. <b><i>Methods:</i></b> A retrospective analysis of patient characteristics and morphologic features associated with EP, EPC in situ and invasive porocarcinoma patients who attended two skin lesion clinics in Italy and Turkey between 2010 and 2011. <b><i>Results:</i></b> A total of 4 cases including 1 EP, 1 EPC in situ and 2 cases of invasive EPC in 4 patients were analyzed. Recent changes including bleeding, ulceration and sudden enlargement of a pre-existing lesion were associated with malignant transformation. Dermoscopically, polymorphous vessels consisting of coiled, hairpin and linear vessels were seen at all stages of progression. Histopathological findings of EPC in situ were limited to the epidermal component and were evident only at higher magnification. <b><i>Conclusions:</i></b> Clinicians and pathologists should carefully evaluate EPs with a recent history of change and erosion in order to avoid overlooking the potential development of EPC

Supplementary Material for: Unknown Primary Melanoma: Worldwide Survey on Clinical Management

<p><b><i>Background:</i></b> How to deal with melanoma of unknown primary (MUP) origin is a debated topic in the literature. <b><i>Objective:</i></b> We performed a worldwide survey to inquire what clinical and investigational workup is performed as well as the physicians' perception of this disease. <b><i>Methods:</i></b> A questionnaire was sent via mail to clinicians involved in melanoma care from December 2015 to April 2016 using the International Dermoscopy Society website. <b><i>Results:</i></b> 119 physicians from 47 different countries answered the questionnaire. The most reported examination was skin examination followed by CT and/or PET scans. All the participants declared asking about previous excisions of skin lesions with 81% of them asking for a histopathological slide review of previous biopsies. Half of the participants checked for a possible vitiligo phenomenon that may explain regression of the primary lesion. <i>BRAF, cKIT,</i> and <i>GNAQ</i> mutations were screened by 32% of participants. The majority of participants (76%) applied the same treatment protocols for MUP as patients with known primary melanomas of the same AJCC stage. <b><i>Conclusion:</i></b> Strong heterogeneity was found between physicians dealing with MUP. Thus, a consensus document should be strongly encouraged.</p