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Micromelanomas: A Review of Melanomas ≤2 mm and a Case Report

Micromelanomas: A Review of Melanomas ≤2 mm and a Case Report Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 206260, 4 pages http://dx.doi.org/10.1155/2014/206260 Case Report Micromelanomas: A Review of Melanomas≤2mm and a Case Report 1,2,3 Sharad P. Paul Skin Surgery Clinic, 271A Blockhouse Bay Road, Auckland, NZ 0600, New Zealand Department of Skin Cancer, School of Medicine, University of Queensland, Qld 4029, Australia FacultyofSurgery,UniversityofAuckland, NZ 1142,New Zealand Correspondence should be addressed to Sharad P. Paul; sharad@sharadpaul.com Received 15 September 2013; Accepted 28 October 2013; Published 19 January 2014 Academic Editors: T.-W. Chang and D. Yin Copyright © 2014 Sharad P. Paul. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The ABCD acronym used to screen pigmented lesions for melanoma obviously was not designed to contend with melanomas that are under 2 mm in diameter. Previously, views ranged that such small lesions could not be melanomas until a few reports of such “micromelanomas” emerged. The author presents a 2 mm melanoma in situ presenting as an insignificant pigmented lesion in a 60-year-old patient with no previous history of melanoma or multiple nevi—which is usually the norm in cases of small melanoma. This paper reiterates the fact that when it comes to a melanoma, size does not matter. In this paper, the term “micromelanoma” is used by the author to represent melanomas under 2 mm. Dermatoscopy and histopathology findings are discussed in this case, along with a review of small melanomas. 1. Background tumor thicknesses ranged from 0.11 to 1.5 mm, with a median thickness of approximately 0.7 mm [6]. In 1985, the oft-quoted ABCD acronym was developed for The author presents a 2 mm melanoma in situ presenting melanoma screening as a public health tool to aid the as asolitarydenovolesionina60-year-oldpatient with no diagnosis of melanomas [1]. Asymmetry, border, color, and previous history of melanoma or multiple nevi—illustrating diameter of the pigmented lesion were parameters discussed the fact that when it comes to a melanoma, established clinical patterns or size do not seem to matter. As many authors in this context. In 1987, Schmoeckel and Braun-Falco even have already stated, the ABCD criteria oeft n does not seem suggested that pigmented lesions under 5 mm cannot be to matter [7, 8]. In this paper, the term “micromelanoma” is considered melanomas as clinical and histological features coined to represent melanomas under 2 mm. only became apparent when lesions enlarged beyond 5 mm The presentation is also unusual because of the age size [2]. Then a study from the Sydney Melanoma Unit and clinical presentation of this lesion not being clinically undertook a large retrospective study and concluded that dieff rent to the patient’s other nevi. Further this patient 31.1%oflesions were 6mmorlessindiameter[3]. After had <5nevioverall.This lesion didnot look particularly adjusting for tissue shrinkage among specimens from this sinister on clinical examination with the naked eye. The Australian cohort, it was reported that only 10% of invasive dermatoscopic and histological aspects are reviewed in the melanomas were small-diameter tumors [4]. A few years context of this clinical case and the associated literature of later, a paper presented a series of invasive small-diameter “micromelanomas.” melanomas, debating if the “D” should be removed from the ABCD acronym [4]. Recently, a case report reviewed the der- matoscopy and dermatopathology ndin fi gs of a tiny invasive 2. Case History melanoma in a 38-year-old patient who had>100 nevi—with the smallest diameter ever of a reported melanoma of 1.6 mm A 60-year-old lady (Caucasian, Fitzpatrick Type 2 skin) [5]. Some groups reported that small-diameter melanoma presented for a screening skin examination with no previous 2 Case Reports in Oncological Medicine Figure 1 Figure 3 (7) white lines, (8) parallel lines on ridges. In the case being described here, the lesion exhibited Figure 2 “chaos” (asymmetry of color or structure) and also a “clue” (grey or blue structure of any kind). er Th efore, excision biopsy was done. Interestingly, this lady had very few (<5) family history or significant personal medical history of nevi and none of the other equally small and pigmented nevi skin cancer. On examination she had a very small 2 mm exhibited any asymmetry. pigmented lesion on her right forearm (Figure 1). She had In dermatoscopy, most two-step algorithms commonly not been aware of this lesion given its tiny size. She had recommended were established to differentiate melanocytic few nevi (<5) andall otherneviappearedequally pigmented from nonmelanocytic lesions as a first step. However, using and around 2 mm in diameter. None of them appeared a“chaosand clues” method helpsusdieff rentiatemalignant particularly dark on clinical examination. from benign lesions rfi st—by looking for chaos over symme- try. In comparing these methods, Tschandl et al. and others 3. Dermatoscopy commented that looking for chaos and clues was preferable— given that the first step of the traditional dermatoscopic 2- Dermatoscopy has now become well established as a tech- step algorithm, if applied consistently, has a low specificity nique to detect early melanomas or to screen pigmented especially in patients with severely sun-damaged skin, as is lesions. On examination with a dermatoscope (Heine Delta often found in Australasia [ 11]. 20 dermatoscope, manufactured by Heine, Optotechnic GmbH, Herrsching, Germany), the lesion being discussed had no obvious melanin network, but it had asymmetry of 4. Histopathology color; further, the blueness suggested that is was probably both melanocytic and atypical (Figure 2). Small melanomas Ferrara et al. suggest that small melanomas need more strin- arenot only missed by theABCDrule, butdermatoscopy gent criteria and a “consensus approach” to diagnosis among is notoriously dicffi ult, with most dermatoscopic algorithms examining pathologists, as there is no gold standard. In their not being useful [9]. study they suggest that severe cytologic atypia represents a Looking for “Chaos and Clues” in dermatoscopy has been useful clue in differentiating small melanomas from small described as an extremely useful method [10]. In this method dysplastic nevi [12]. “chaos” is defined as the presence of asymmetry in structure Sections here show supercfi ial sun-damaged skin bear- or color. In the presence of “chaos” one looks for any of the ing a small proliferation of atypical melanocytes showing following eight clues: pagetoid scatter to the granular layer along with trans- epidermal elimination of melanin pigment. Superficial der- (1) thick reticular lines, mis shows melanophages and there is no dermal invasion. (2) grey or blue structures of any kind, eTh appearance is suggestive of a melanoma in situ because of (3) pseudopods or radial lines at the periphery, the combination of cytologic atypia and epidermal invasion (Figures 3, 4,and 5). Figure 3 shows the biopsy specimen; (4) black dots in the periphery, Figure 4 shows atypical hyperchromatic melanocytes singly (5) eccentric structure-less area of any color, and in nests; and Figure 5 shows transepidermal (pagetoid) (6) polymorphous vascular pattern, invasion. Case Reports in Oncological Medicine 3 >100 nevi. Our patient exhibited neither of the above clinical features. eTh lesion was one of 4 nevi and all appeared similar to the naked eye and not particularly abnormal. However, when all the nevi were examined using a dermatoscope, this particular lesion proved significant when using the “chaos and clues” method of dermatoscopy; histology confirmed features of a melanoma in situ. eTh refore, this case further serves to reinforce that when it comes to melanoma or melanoma in situ, size or number of nevi does not matter. Further, using dermatoscopy one is able to diagnose these “micromelanomas” at a very early stage of evolution—both from a histological and dimensional point of view. Figure 4 Conflict of Interests eTh author declares that there is no conflict of interests regarding the publication of this paper. References [1] R. J. Friedman, D. S. Rigel, and A. W. Kopf, “Early detection of malignant melanoma: the role of physician examination and self-examination of the skin,” Ca: Cancer Journal for Clinicians, vol. 35,no. 3, pp.130–151,1985. [2] C. Schmoeckel and O. Braun-Falco, “Diagnosis of early malig- nant melanoma: sensitivity and specificity of clinical and histological criteria,” in Pathobiology of Malignant Melanoma, Figure 5 D. E. Elder, Ed., vol. 8, pp. 96–106, Karger, Basel, Switzerland, [3] H. M. Shaw and W. H. McCarthy, “Small-diameter malignant melanoma: a common diagnosis in New South Wales, Aus- 5. Discussion tralia,” Journal of the American Academy of Dermatology,vol. Micromelanomas (used by the author to denote melanomas 27,no. 5, part 1, pp.679–682,1992. under 2 mm diameter) as discussed earlier naturally will not [4] N. R. Abbasi, H. M. Shaw, D. S. Rigel et al., “Early diagnosis tfi the ABCD acronym. In earlier studies of pigmented lesions of cutaneous melanoma: revisiting the ABCD criteria,” Journal of the American Medical Association,vol.292,no. 22,pp. 2771– 3 to 6 mm in diameter, authors showed that clinical criteria 2776, 2004. for diagnosing melanoma are not as reliable in the case of pigmented lesions less than 6 mm diameter [13]. In this case [5] R. Bergman, I. Katz, C. Lichtig, Y. Ben-Arieh, A. R. Moscona, and R. Friedman-Birnbaum, “Malignant melanomas with his- of a tiny pigmented lesion of 2 mm diameter, the unusual tologic diameters less than 6 mm,” Journal of the American features were the absence of several nevi, which is usually the Academy of Dermatology,vol.26, no.3,pp. 462–466, 1992. caseinotherreportedcases.Inthissituation,thiswastheonly [6] A.Gonzalez, A. J. West,J.V.Pitha,and J. W. Taira, “Small- nevus that exhibited any chaos and therefore using the “chaos diameter invasive melanomas: clinical and pathologic charac- and clues” algorithm proved decisive. teristics,” JournalofCutaneous Pathology,vol.23, no.2,pp. 126– The lesion turned out to be a melanoma in situ and was 132, 1996. managedbywidesurgicalexcisiontoensure5mm margins [7] E.M.Fernandez andK.F.Helm, “ed Th iameterofmelanomas,” all around. eTh re were no complications or further issues to Dermatologic Surgery,vol.30, no.9,pp. 1219–1222,2004. do with this lesion. [8] A.A.Marghoob, J. Slade, A. W. Kopf,D.S.Rigel,and R. J. Friedman, “The ABCDs of melanoma: why change?” Journal of 6. Conclusion the American Academy of Dermatology,vol.32, no.4,pp. 682– 684, 1995. Micromelanomas, melanomas under 2 mm, are being [9] G.Pellizzari,J.Magee,D.Weedon,and C. Rosendahl, “A increasingly reported and given the minute size, the ABCD tiny invasive melanoma: a case report with dermatoscopy and screening acronym becomes redundant. Further, traditional dermatopathology,” Dermatology Practical & Conceptual,vol.3, two-dermatoscopic diagnostic methods often fail and the no. 2, pp. 49–51, 2013. “chaos and clues” algorithm may be the better method to fol- [10] C. Rosendahl, A. Cameron, I. McColl, and D. Wilkinson, low while performing dermatoscopy. In previously reported “Dermatoscopy in routine practice: ‘chaos and clues’,” Australian micromelanomas, the lesions were noted to be darker Family Physician,vol.41, no.7,pp. 482–487, 2012. than other nevi (the so-called “ugly duckling” sign) [14]. [11] P. Tschandl, C. Rosendahl, and H. Kittler, “Accuracy of the Further, patients usually had dysplastic nevus syndrome with first step of the dermatoscopic 2-step algorithm for pigmented 4 Case Reports in Oncological Medicine skin lesions,” Dermatology Practical & Conceptual,vol.2,no. 3, article 8, 2012. [12] G. Ferrara, C. Tomasini, G. Argenziano, I. Zalaudek, and C. M. Stefanato, “Small-diameter melanoma: toward a conceptual and practical reappraisal,” Journal of Cutaneous Pathology,vol.39, no.7,pp. 721–723, 2012. [13] V. de Giorgi, I. Savarese, S. Rossari et al., “Features of small melanocytic lesions: does small mean benign? A clinical- dermoscopic study,” Melanoma Research,vol.22, no.3,pp. 252– 256, 2012. [14] M. Inskip, J. Magee, D. Weedon, and C. Rosendahl, “When algorithms falter: a case report of a very small melanoma excised due to the dermatoscopic “ugly duckling” sign,” Dermatology Practical & Conceptual,vol.3,no. 2, pp.59–62,2013. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Micromelanomas: A Review of Melanomas ≤2 mm and a Case Report

Case Reports in Oncological Medicine , Volume 2014 – Jan 19, 2014

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Hindawi Publishing Corporation
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Copyright © 2014 Sharad P. Paul. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2014/206260
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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 206260, 4 pages http://dx.doi.org/10.1155/2014/206260 Case Report Micromelanomas: A Review of Melanomas≤2mm and a Case Report 1,2,3 Sharad P. Paul Skin Surgery Clinic, 271A Blockhouse Bay Road, Auckland, NZ 0600, New Zealand Department of Skin Cancer, School of Medicine, University of Queensland, Qld 4029, Australia FacultyofSurgery,UniversityofAuckland, NZ 1142,New Zealand Correspondence should be addressed to Sharad P. Paul; sharad@sharadpaul.com Received 15 September 2013; Accepted 28 October 2013; Published 19 January 2014 Academic Editors: T.-W. Chang and D. Yin Copyright © 2014 Sharad P. Paul. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The ABCD acronym used to screen pigmented lesions for melanoma obviously was not designed to contend with melanomas that are under 2 mm in diameter. Previously, views ranged that such small lesions could not be melanomas until a few reports of such “micromelanomas” emerged. The author presents a 2 mm melanoma in situ presenting as an insignificant pigmented lesion in a 60-year-old patient with no previous history of melanoma or multiple nevi—which is usually the norm in cases of small melanoma. This paper reiterates the fact that when it comes to a melanoma, size does not matter. In this paper, the term “micromelanoma” is used by the author to represent melanomas under 2 mm. Dermatoscopy and histopathology findings are discussed in this case, along with a review of small melanomas. 1. Background tumor thicknesses ranged from 0.11 to 1.5 mm, with a median thickness of approximately 0.7 mm [6]. In 1985, the oft-quoted ABCD acronym was developed for The author presents a 2 mm melanoma in situ presenting melanoma screening as a public health tool to aid the as asolitarydenovolesionina60-year-oldpatient with no diagnosis of melanomas [1]. Asymmetry, border, color, and previous history of melanoma or multiple nevi—illustrating diameter of the pigmented lesion were parameters discussed the fact that when it comes to a melanoma, established clinical patterns or size do not seem to matter. As many authors in this context. In 1987, Schmoeckel and Braun-Falco even have already stated, the ABCD criteria oeft n does not seem suggested that pigmented lesions under 5 mm cannot be to matter [7, 8]. In this paper, the term “micromelanoma” is considered melanomas as clinical and histological features coined to represent melanomas under 2 mm. only became apparent when lesions enlarged beyond 5 mm The presentation is also unusual because of the age size [2]. Then a study from the Sydney Melanoma Unit and clinical presentation of this lesion not being clinically undertook a large retrospective study and concluded that dieff rent to the patient’s other nevi. Further this patient 31.1%oflesions were 6mmorlessindiameter[3]. After had <5nevioverall.This lesion didnot look particularly adjusting for tissue shrinkage among specimens from this sinister on clinical examination with the naked eye. The Australian cohort, it was reported that only 10% of invasive dermatoscopic and histological aspects are reviewed in the melanomas were small-diameter tumors [4]. A few years context of this clinical case and the associated literature of later, a paper presented a series of invasive small-diameter “micromelanomas.” melanomas, debating if the “D” should be removed from the ABCD acronym [4]. Recently, a case report reviewed the der- matoscopy and dermatopathology ndin fi gs of a tiny invasive 2. Case History melanoma in a 38-year-old patient who had>100 nevi—with the smallest diameter ever of a reported melanoma of 1.6 mm A 60-year-old lady (Caucasian, Fitzpatrick Type 2 skin) [5]. Some groups reported that small-diameter melanoma presented for a screening skin examination with no previous 2 Case Reports in Oncological Medicine Figure 1 Figure 3 (7) white lines, (8) parallel lines on ridges. In the case being described here, the lesion exhibited Figure 2 “chaos” (asymmetry of color or structure) and also a “clue” (grey or blue structure of any kind). er Th efore, excision biopsy was done. Interestingly, this lady had very few (<5) family history or significant personal medical history of nevi and none of the other equally small and pigmented nevi skin cancer. On examination she had a very small 2 mm exhibited any asymmetry. pigmented lesion on her right forearm (Figure 1). She had In dermatoscopy, most two-step algorithms commonly not been aware of this lesion given its tiny size. She had recommended were established to differentiate melanocytic few nevi (<5) andall otherneviappearedequally pigmented from nonmelanocytic lesions as a first step. However, using and around 2 mm in diameter. None of them appeared a“chaosand clues” method helpsusdieff rentiatemalignant particularly dark on clinical examination. from benign lesions rfi st—by looking for chaos over symme- try. In comparing these methods, Tschandl et al. and others 3. Dermatoscopy commented that looking for chaos and clues was preferable— given that the first step of the traditional dermatoscopic 2- Dermatoscopy has now become well established as a tech- step algorithm, if applied consistently, has a low specificity nique to detect early melanomas or to screen pigmented especially in patients with severely sun-damaged skin, as is lesions. On examination with a dermatoscope (Heine Delta often found in Australasia [ 11]. 20 dermatoscope, manufactured by Heine, Optotechnic GmbH, Herrsching, Germany), the lesion being discussed had no obvious melanin network, but it had asymmetry of 4. Histopathology color; further, the blueness suggested that is was probably both melanocytic and atypical (Figure 2). Small melanomas Ferrara et al. suggest that small melanomas need more strin- arenot only missed by theABCDrule, butdermatoscopy gent criteria and a “consensus approach” to diagnosis among is notoriously dicffi ult, with most dermatoscopic algorithms examining pathologists, as there is no gold standard. In their not being useful [9]. study they suggest that severe cytologic atypia represents a Looking for “Chaos and Clues” in dermatoscopy has been useful clue in differentiating small melanomas from small described as an extremely useful method [10]. In this method dysplastic nevi [12]. “chaos” is defined as the presence of asymmetry in structure Sections here show supercfi ial sun-damaged skin bear- or color. In the presence of “chaos” one looks for any of the ing a small proliferation of atypical melanocytes showing following eight clues: pagetoid scatter to the granular layer along with trans- epidermal elimination of melanin pigment. Superficial der- (1) thick reticular lines, mis shows melanophages and there is no dermal invasion. (2) grey or blue structures of any kind, eTh appearance is suggestive of a melanoma in situ because of (3) pseudopods or radial lines at the periphery, the combination of cytologic atypia and epidermal invasion (Figures 3, 4,and 5). Figure 3 shows the biopsy specimen; (4) black dots in the periphery, Figure 4 shows atypical hyperchromatic melanocytes singly (5) eccentric structure-less area of any color, and in nests; and Figure 5 shows transepidermal (pagetoid) (6) polymorphous vascular pattern, invasion. Case Reports in Oncological Medicine 3 >100 nevi. Our patient exhibited neither of the above clinical features. eTh lesion was one of 4 nevi and all appeared similar to the naked eye and not particularly abnormal. However, when all the nevi were examined using a dermatoscope, this particular lesion proved significant when using the “chaos and clues” method of dermatoscopy; histology confirmed features of a melanoma in situ. eTh refore, this case further serves to reinforce that when it comes to melanoma or melanoma in situ, size or number of nevi does not matter. Further, using dermatoscopy one is able to diagnose these “micromelanomas” at a very early stage of evolution—both from a histological and dimensional point of view. Figure 4 Conflict of Interests eTh author declares that there is no conflict of interests regarding the publication of this paper. References [1] R. J. Friedman, D. S. Rigel, and A. W. Kopf, “Early detection of malignant melanoma: the role of physician examination and self-examination of the skin,” Ca: Cancer Journal for Clinicians, vol. 35,no. 3, pp.130–151,1985. [2] C. Schmoeckel and O. Braun-Falco, “Diagnosis of early malig- nant melanoma: sensitivity and specificity of clinical and histological criteria,” in Pathobiology of Malignant Melanoma, Figure 5 D. E. Elder, Ed., vol. 8, pp. 96–106, Karger, Basel, Switzerland, [3] H. M. Shaw and W. H. McCarthy, “Small-diameter malignant melanoma: a common diagnosis in New South Wales, Aus- 5. Discussion tralia,” Journal of the American Academy of Dermatology,vol. Micromelanomas (used by the author to denote melanomas 27,no. 5, part 1, pp.679–682,1992. under 2 mm diameter) as discussed earlier naturally will not [4] N. R. Abbasi, H. M. Shaw, D. S. Rigel et al., “Early diagnosis tfi the ABCD acronym. In earlier studies of pigmented lesions of cutaneous melanoma: revisiting the ABCD criteria,” Journal of the American Medical Association,vol.292,no. 22,pp. 2771– 3 to 6 mm in diameter, authors showed that clinical criteria 2776, 2004. for diagnosing melanoma are not as reliable in the case of pigmented lesions less than 6 mm diameter [13]. In this case [5] R. Bergman, I. Katz, C. Lichtig, Y. Ben-Arieh, A. R. Moscona, and R. Friedman-Birnbaum, “Malignant melanomas with his- of a tiny pigmented lesion of 2 mm diameter, the unusual tologic diameters less than 6 mm,” Journal of the American features were the absence of several nevi, which is usually the Academy of Dermatology,vol.26, no.3,pp. 462–466, 1992. caseinotherreportedcases.Inthissituation,thiswastheonly [6] A.Gonzalez, A. J. West,J.V.Pitha,and J. W. Taira, “Small- nevus that exhibited any chaos and therefore using the “chaos diameter invasive melanomas: clinical and pathologic charac- and clues” algorithm proved decisive. teristics,” JournalofCutaneous Pathology,vol.23, no.2,pp. 126– The lesion turned out to be a melanoma in situ and was 132, 1996. managedbywidesurgicalexcisiontoensure5mm margins [7] E.M.Fernandez andK.F.Helm, “ed Th iameterofmelanomas,” all around. eTh re were no complications or further issues to Dermatologic Surgery,vol.30, no.9,pp. 1219–1222,2004. do with this lesion. [8] A.A.Marghoob, J. Slade, A. W. Kopf,D.S.Rigel,and R. J. Friedman, “The ABCDs of melanoma: why change?” Journal of 6. Conclusion the American Academy of Dermatology,vol.32, no.4,pp. 682– 684, 1995. Micromelanomas, melanomas under 2 mm, are being [9] G.Pellizzari,J.Magee,D.Weedon,and C. Rosendahl, “A increasingly reported and given the minute size, the ABCD tiny invasive melanoma: a case report with dermatoscopy and screening acronym becomes redundant. Further, traditional dermatopathology,” Dermatology Practical & Conceptual,vol.3, two-dermatoscopic diagnostic methods often fail and the no. 2, pp. 49–51, 2013. “chaos and clues” algorithm may be the better method to fol- [10] C. Rosendahl, A. Cameron, I. McColl, and D. Wilkinson, low while performing dermatoscopy. In previously reported “Dermatoscopy in routine practice: ‘chaos and clues’,” Australian micromelanomas, the lesions were noted to be darker Family Physician,vol.41, no.7,pp. 482–487, 2012. than other nevi (the so-called “ugly duckling” sign) [14]. [11] P. Tschandl, C. Rosendahl, and H. Kittler, “Accuracy of the Further, patients usually had dysplastic nevus syndrome with first step of the dermatoscopic 2-step algorithm for pigmented 4 Case Reports in Oncological Medicine skin lesions,” Dermatology Practical & Conceptual,vol.2,no. 3, article 8, 2012. [12] G. Ferrara, C. Tomasini, G. Argenziano, I. Zalaudek, and C. M. Stefanato, “Small-diameter melanoma: toward a conceptual and practical reappraisal,” Journal of Cutaneous Pathology,vol.39, no.7,pp. 721–723, 2012. [13] V. de Giorgi, I. Savarese, S. Rossari et al., “Features of small melanocytic lesions: does small mean benign? A clinical- dermoscopic study,” Melanoma Research,vol.22, no.3,pp. 252– 256, 2012. [14] M. Inskip, J. Magee, D. Weedon, and C. Rosendahl, “When algorithms falter: a case report of a very small melanoma excised due to the dermatoscopic “ugly duckling” sign,” Dermatology Practical & Conceptual,vol.3,no. 2, pp.59–62,2013. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

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