Disorders Techniques in Investigation and Diagnosis - part 9 ppsx

Nail melanoma Melanoma of the nail apparatus most commonly derives from the matrix, much less frequently from the nail bed or hyponychium. Matrix melanoma usually causes longitudinal melanonychia (see Chapter 5). Whether atypical melanocytic hyperplasia is already subungual in situ melanoma is not entirely clear. Large, atypical melanocytes in all layers of the matrix and nail bed epithelium, pycnotic melanocytes in the nail plate mirroring the pagetoid spread in the epithelium, and mitoses, are seen as proof of a malignant melanoma. Sometimes nail clippings reveal single intraungual pycnotic melanoma cells which retain their protein S-100 positivity. Most subungual melanomas are of acrolentiginous type; however, those in the nail bed tend instead to be nodular melanomas. Even long-standing melanomas are often still very superficial. Invasive melanomas have therefore usually a decade-long history. Epidermoid carcinoma The term ‘epidermoid carcinoma’ denotes both ungual Bowen’s disease and squamous cell carcinoma. Commonly originating from the lateral sulcus, Bowen’s disease slowly spreads under and around the nail. Histologically, all changes typical of Bowen’s disease of the skin are seen: loss of orderly architecture and polarity of basal cells, atypical nuclei, pathological mitoses, some giant cells, dyskeratoses, often vacuolization, and even clear cells. After decades the lesion develops into invasive squamous cell carcinoma, which, however, may also develop without prior bowenoid changes. Malignant onycholemmal cyst is probably a particular form of Bowen’s disease, as was seen in a case in which the cyst, after incomplete removal, rapidly showed the features of typical squamous cell carcinoma (author’s unpublished observation). FURTHER READING Alessi E, Zorzi F, Gianotti R, Parafiori A (1994) Malignant proliferating onycholemmal cyst, J Cut Pathol 21: 183–188. Baran R, Goettmann S (1998) Distal digital keratoacanthoma: a report of 12 cases and review of the literature, Br J Dermatol 139: 512–515. Baran R, Kint A (1992) Onychomatrixoma. Filamentous tufted tumour in the matrix o f a funnel-shaped nail: a new entity, Br J Dermatol 126: 510–515. Blessing K, Kernohan NM, Park KGM (1991) Subungual malignant melanoma. Clinico-pathological features of 100 cases, Histopathology 19: 425–429. Davies MG (1995) Coccal nail fold angiomatosis, Br J Dermatol 132: 162–163. Haneke E (1983) Onycholemmal horn, Dermatologica 167: 155–158. Haneke E (1988) Operative Therapie der myxoiden Pseudocyste. In: Gegenwärtiger Stand der operativen Dermatologie, Haneke E, ed. (Berlin, Springer) pp. 221–227. Haneke E (1991) Multiple subungual keratoacanthomas, Zbl Haut GeschlKr 159: 337– Histopathology of common nail conditions 277 338. Haneke E (1991) Epidermoid carcinoma (Bowen’s disease) of the nail simulating acquired fibrokeratoma, Skin Cancer 6: 217–221. Haneke E, Fränken J (1995) Onychomatricoma, Dermatol Surg 21: 984–987. Kint A, Baran R (1988) Histopathologic study of Koenen tumours, J Am Acad Dermatol 18: 369–372. Malvehy J, Palou J, Mascaró JM (1998) Painful subungual tumour in incontinentia pigmenti. Response to treatment with etretinate, Br J Dermatol 138: 554–555. A text atlas of nail disorders 278 [...]... preoperatively FURTHER READING Alexander H, Miller DL ( 197 9) Determining skin thickness with pulsed ultrasound, J Invest Dermatol 72:17– 19 Baran R, Kechijian P ( 198 9) Longitudinal melanonychia: diagnosis and management, J Am Acad Dermatol 21:1165–1175 Baran R, Klint A ( 199 2) Onychomatrixoma, Br J Dermatol 126:510–515 Bittoun J, Leroy-Willig A, Idy I et al ( 198 7) Relation entre rapport signal-sur-bruit et paramètres... Graham WP, Blomain EW ( 198 6) A ten-year experience with glomus tumors, Ann Plast Surg 6: 297 – 299 Drapé JL, Thelen P, Gay-Depassier P et al ( 199 3) Intraarticular diffusion of Gd-DPTA after intravenous injection in the knee: MR imaging evaluation, Radiology 188:227– 234 Drapé JL, Idy-Peretti I, Goettmann S et al ( 199 5) MR imaging of subungual glomus tumors, Radiology 195 :507–515 Drapé JL, Idy-Peretti I, Goettmann... equipment In: Ultrasound in Dermatology, eds Altmeyer P, EI-Gammal S, Hoffmann K (Berlin, Springer) pp 41– 54 Tan CY, Marks R, Payne P ( 198 1) Comparison of xeroradiographic and ultrasound detection of corticosteroid induced dermal thinning, J Invest Dermatol 76:126–128 Varian J, Cleak DK ( 198 0) Glomus tumors in the hand, Hand 12: 293 – 299 12 Dermoscopy of nail pigmentation Luc Thomas and Sandra Ronger... et al ( 199 2) Forty-eight glomus tumors of the hand: retrospective study and four-year follow-up, Ann Hand Surg 11:401–405 Goldman L ( 196 2) Transillumination of the fingertip as aid in examination of the nail changes, Arch Dermatol Chicago 85:644 Hirai T, Fumiiri M ( 199 5) Ultrasonic observation of the nail matrix, Dermatol Surg 21:158–161 Hou SM, Shih TTF, Lin MC ( 199 3) Magnetic resonance imaging of... S et al ( 199 6) MR imaging of digital mucoid cysts, Radiology 200:531–536 Drewers J, Günther D, Nolden HH ( 198 5) Intraossäre epidermiszysten der finger und zehen, Akt Chir 20:171 EI-Gammal S, Hoffmann K, Auer T et al ( 199 1) A 50-MHz high-resolution ultrasound imaging system for dermatology In: Ultrasound in Dermatology, eds Altemeyer P, EI-Gammal S , Hoffmann K (Berlin, Springer) pp 41–54 Finlay AY,... N ( 199 3) Ultrasonography of a subungual glomus tumour, J Hand Surg 18B: 746–747 Rettig AC, Strickland JW ( 197 7) Glomus tumors of the digits, J Hand Surg 2A: 261– 265 Schneider LH, Bachow TB ( 199 1) Magnetic resonance imaging of glomus tumor, Orthop Rev 20:255–256 Serup J ( 199 1) Ten year’s experience with high-frequency ultrasound examination of the skin: development and refinement of technique and equipment... Figure 11.21 Keratoacanthoma Sagittal post-gadolinium T1-weighted image Ultrasonography and magnetic resonance 299 showing strong peripheral enhancement (arrow) and acro-osteolysis (arrowhead) the crater, but this is inconstant The limits may be ill defined owing to oedema in the surrounding tissues Magnetic resonance images show a deep infiltrating lesion and detect more accurately than radiographs... which are particularly numerous in the dermis of the nail bed High-resolution MRI is able to depict normal glomus bodies with T2–weighted images and following injection of gadolinium The classic triad associating pain, tenderness to pressure and cold sensitivity is evocative but infrequent Imaging appears helpful to the diagnosis in 68% of cases The mean diagnostic delay, varying from 4 to 7 years in published... lentigo, drug-induced pigmentation, subungual haemorrhage and ethnic-type nail pigmentation The ‘gold standard’ of diagnosis remains the pathological examination of the nail matrix biopsy, but the biopsy procedure is usually painful and often results in nail dystrophy Clinical criteria have been defined in an attempt to discriminate between suspect lesions that should undergo nail apparatus biopsy and less... pigmented band and can be observed in several nail conditions In our opinion these grooves are non-specific and do not indicate any diagnosis (see Figure 12.8) DIAGNOSIS Nail apparatus naevus Nail apparatus pigmented naevus is characterized dermoscopically by the presence of a brown background and regularly spaced, thick and pigmented longitudinal lines The colour of the background and of the bands varies . imaging. Very high-resolution ultrasonographic studies are still restricted to the field o f research, beginning with skin imaging in 197 9. Ultrasonography appeared as an effective and non-invasive. Both A-mode and B- mode ultrasonographs dedicated to skin imaging have been developed as research and clinical tools, mainly for tumoral and inflammatory diseases. The role of M-mode, high- frequency. and following injection of gadolinium. The classic triad associating p ain, tenderness to pressure and cold sensitivity is evocative but infrequent. Imaging appears helpful to the diagnosis in