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Two step algorithm (melanocytic vs non-melanocytic) Flashcards

1
Q

What is the main purpose of the 2-step algorithm?

A

Avoid missing the diagnosis of melanoma

Designed to maximize the sensitivity for melanoma detection

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2
Q

Limitations of the 2-step algorithm

A

Designed to evaluate lesions on glabrous & nonglabrous skin only

Not intended for evaluation of nail,mucosa, hair abnormalities

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3
Q

Algorithm for the differentiation btw melanocytic & nonmelanocytic lesions

A
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4
Q

1st step in 2-step algorithm

A

Decide whether a lesion is of melanocytic or nonmelanocytic origin

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5
Q

1st step is composed of how many levels?

A

7 levels

Each of which requires the
clinician to search for specific structures and criteria

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6
Q

Name the 7 decision levels of the first step

A

Criteria for

  • Level 1: Melanocytic lesions
  • Level 2: BCC
  • Level 3: SKs
  • Level 4: Vascular lesions
  • Level 5: Specific blood vessels for nonmelanocytic neoplasms
  • Level 6: Specific blood vessels for melanocytic lesions
  • Level 7: Structureless
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7
Q

All lesions in level 7 are considered…?

A

Melanocytic by default

Melanoma needs to be considered in the DDx

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8
Q

2nd step in the 2-step algorithm

A

Determine whether the presumed melanocytic lesion from step 1

is benign, suspect, or malignant

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9
Q

Two-step procedure for the differential diagnosis of pigmented lesions

A
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10
Q

What does the 1st level of step 1 consist of?

A

Criteria for melanocytic lesions

  • Pigment network
  • branched streaks (e.g., atypical network)
  • streaks (i.e., radial streaming and pseudopods)
  • negative network
  • aggregated globules
  • homogenous blue pigmentation
  • pseudonetwork (face)
  • parallel pattern (palms, soles, and mucosa)
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11
Q

If any of the criteria in level 1 are met, what is the BNS?

A

Lesion is considered of melanocytic origin

Proceed directly to the 2nd step of the 2-step algorithm

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12
Q

Name one major exception of 1st level

A

Dermatofibroma

Delicate peripheral network with a central scar-like area

(as seen in NPD)

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13
Q

How to differentiate a blue nevus from other lesions

A

Blue-white veil that’s covers the ENTIRE lesion

in a HOMOGENOUS manner (NPD)

ps: in PD blue nevus reveal different shades or hues of blue

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14
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Typical regular pn (Level 1)

Thinning out toward the periphery

Junctional nevus

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15
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Atypical pn

Branched streaks

Dysplastic nevus

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16
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Globular architecture

multiple round & ovoid globules

Compound nevus

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17
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Homogenous blue veil pigmentation

that covers the ENTIRE lesion

Blue nevus

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18
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Typical regular pseudonetwork

Compound nevus of the face

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19
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Lattice-like pattern

variation of the parallel furrow pattern

Junctional nevus, palm

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20
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Irregular confluent bluish-whitish pigmentation

does NOT occupy the entire surface area of the lesion

Malignant melanoma

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21
Q

None of the criteria of level 1 are met, BNS?

A

Proceed to level 2

Criteria for BCC

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22
Q

Name the criteria for BCC

A
  1. ​Arborizing blood vessels (telangiectasias)
  2. Leaf-like areas
  3. Large blue-gray ovoid nests
  4. Multiple blue-gray non-aggregated globules
  5. Spoke-wheel-like structures
  6. Shiny white areas
  7. Ulceration
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23
Q

Condition under which, presence of level 2 criteria are ^ suggestive of BCC?

A

Absence of pigment network

NEVER SKIP level 1

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24
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Arborizing telangiectasia (arrows)

Ulceration (arrowheads)

Multiple leaf-like areas (asterisks)

pBCC

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25
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Multiple blue-gray ovoid nests (arrows)

Leaf-like areas

Telangiectasia (left part)

Nodular pBCC

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26
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Multiple blue-gray non-aggregated globules (arrows)

blue-gray ovoid nests

ulceration (asterisks)

arborized telan- giectasia (arrowheads)

pBCC

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27
Q

If none of the criteria of level 2 are met, BNS?

A

Proceed to level 3

Criteria for SKs

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28
Q

Name the criteria for SKs

A
  1. Multiple milia-like cysts
  2. Comedo-like openings
  3. Crypts
  4. Moth-eaten borders
  5. Network-like structures
  6. Fissures and ridges (aka gyri & sulci)
  7. Fingerprint-like structures
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29
Q

Does presence of milia cysts equate Dx of SK?

A

No

  • DDx:
  1. SKs
  2. BCC
  3. Melanocytic nevi (especially congenital type)

If 2,3 are excluded then milia cysts are a diagnostic criterion

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30
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

multiple milia- like cysts (arrows)

comedo-like openings (asterisks)

network-like structures (dotted areas) at the periphery

pSK

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31
Q

How to DDx a SK from a melanocytic lesion?

A

Examine the lesion on side-lighting

=> cerebriform appearance by gyri/sulci will be more evident & easier to DD from pigment network

32
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Multiple comedo-like openings

crypt in the right part of the lesion (arrows)

pSK

33
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

moth-eaten border (arrows)

multiple milia-like cysts (aster- isks)

pSK , face

34
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

fat finger-like structures (arrows)

multiple milia-like cysts

SK, face

35
Q

If none of the SK criteria are seen, BNS?

A

Proceed to level 4

Criteria for vascular lesions

36
Q

Name the criteria for vascular lesions , DDx?

A

Presence of red, maroon, or red-blue to black lacunae

  • DDx:
  1. Hemangioma
  2. Angiokeratoma
37
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Multiple dark red lacunae

Hemangioma

38
Q

If the criteria for levels 1–4 have not been satisfied, BNS?

A

Proceed to level 5

Specific Blood Vessels in Nonmelanocytic Lesions

39
Q

Name some specific patterns of blood vessels seen in hypo- /non- melanocytic lesions

A
  • Hairpin vessels with whitish halo
  • Glomerular vessels, at the periphery
  • Serpiginous vessels
  • Crown vessels
40
Q

Regular vs irregular DDx of hairpin vessels

(Vessels that double back on themselves, seen as loops,

surrounded by a hypopigmented halo)

A
  • Regular: SK
  • Irregular: Melanoma, Spitz nevus, keratoacanthoma
41
Q

DDx of crown vessels

(barely branching peripheral vessels that do not cross the center of the lesion)

A
  • Sebaceous hyperplasia
  • Molluscum contagiosum
42
Q

Vessel morphology

43
Q

DDx based on vessel morphology

44
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Elongated hairpin blood vessels with whitish halo

central ulceration with blood crusts

central keratotic plug

– Keratoacanthoma

45
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Glomerular (coiled) vessels

Clustered vascular pattern

hyperkeratosis (surface scale)

non-pigmented Bowen’s disease

46
Q

DDx of glomerular vessels

A

Bowen’s disease

SCC

47
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

“String of pearls” vessel pattern

Clear cell acanthoma

48
Q

Progression model of keratinocytes skin cancer

49
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Crown vessels

Molluscum contagiosum

50
Q

If the criteria for levels 1–5 have not been satisfied, BNS?

A

Proceed to level 6

Search for specific vessels in melanocytic lesions

51
Q

Name some specific patterns of vessels in melanocytic lesions

A
  • Comma- shaped blood vessels, hallmark of intradermal nevi
  • Pinpoint or dotted
  • Corkscrew vessels
  • Polymorphic vessels
52
Q

Polymorphic vessels DDx?

(when two or more types of vessel morphologies are detected)

A
  • Melanoma (serpentine + dotted)
  • SCC (hairpin + glomerular)
53
Q

Comma-shaped vessels DDx

A
  • Dermal nevus (!!!)
  • Compound, congenital nevi
  • BCC, melanoma (less often)
54
Q

Corkscrew/tortuous vessels DDx

A
  • Melanoma (nodular , desmoplastic)
  • Melanoma metastasis
  • BCC
55
Q

Arborizing vessels DDx

A
  • BCC (hallmark)
  • Nodular melanoma
  • Juvenile xanthogranuloma
  • Merkel cell carcinoma
  • Intradermal nevi
56
Q

Milky red globules/areas DDx

A
  • Invasive melanoma (thick amelanotic melanoma)
  • Merkel CC (MCC)
  • BCC
    Pyogenic granuloma (PG)
57
Q

Strawberry pattern DDx?

A

Nonpigmented facial AK

58
Q

Name the blood vessel pattern and their DDx

A
  1. Crown/radial: Senile sebaceous hyperplasia, Molluscum contagiosum, keratoacanthoma
  2. Serpiginous: Clear cell acanthoma
  3. Arborizing: BCC
  4. Clustered: Bowen
  5. Centered dots: Spitz nevi, amelanotic/hypomelanotic melanoma
59
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Comma-shaped vessels

Dermal nevus

60
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Dotted vessels

Melanoma

61
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Corkscrew/tortuous vessels (white arrowheads)

linear irregular vessels (blue arrowheads)

in a pink background

Amelanotic/hypomelanotic nodular melanoma

62
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Hairpin vessels with whitish halo

SK

63
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Glomerular vessels (regularly arranged)

Bowen’s disease

64
Q

Describe the major dermoscopic findings in this lesion

Dx?

A

Arborizing vessels

BCC

65
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Pearls on a string or serpiginous pattern vessels

Clear cell acanthoma

66
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Crown vessels

Sebaceous hyperplasia

67
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Strawberry pattern

Keratotic and plugging follicles with a reddish background caused by ^ superficial vascular volume

Actinic keratosis

68
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Milky red areas/globules

Thick hypomelanotic melanoma

69
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Red‐purple lacunae

Angiokeratoma

70
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Strawberry pattern

pink/red pseudonetwork with blurry vessels

btw hair follicle openings filled with keratotic plugs

Non-pigmented facial AK

71
Q

Milky red color represents…?

A
  • ^ vascular volume
  • reflection of neoangiogenesis
72
Q

If the criteria for levels 1–6 have not been satisfied, BNS?

A

Proceed to level 7

Search for structureless lesions

73
Q

Management of level 7 lesions

A

Biopsy or short-term mole monitoring

You MUST avoid missing melanomas (worst case scenario)

74
Q

Name some possible patterns of level 7 lesions

A
  • Structureless/ featureless
  • Fine dots
  • Peppering
  • Blue-white veil
  • Crystalline structure
  • Blotches
75
Q

Describe the major dermoscopic finding in this lesion

Dx?

A

Blue-white veil

that does NOT cover the entire lesion

Malignant melanoma

76
Q

Which level of lesions from step-1 can be subjected to the 2nd step of the 2-step algorithm?

A
  • Level 1 (melanocytic lesions)
  • Level 6
  • Level 7

Δερματοσκόπηση (4 decks)

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