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Editorial |

Remodeling of the Dermoepidermal Junction in Superficial Spreading Melanoma Insights Gained From Correlation of Dermoscopy, Reflectance Confocal Microscopy, and Histopathologic Analysis

Alon Scope, MD; Iris Zalaudek, MD; Gerardo Ferrara, MD; Giuseppe Argenziano, MD; Ralph P. Braun, MD; Ashfaq A. Marghoob, MD
Arch Dermatol. 2008;144(12):1644-1649. doi:10.1001/archdermatol.2008.504.
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Diagnosis in dermatology, whether rendered clinically or histopathologically, relies on the analytical examination of the primary morphologic features of the lesion on the gross or microscopic level, respectively. During the past 2 decades, we have begun to appreciate a new dimension in primary morphologic analysis, namely, the in vivo, en face macroscopic and microscopic morphologic features as seen via dermoscopy and reflectance confocal microscopy (RCM). Like dermoscopy, RCM reveals morphologic details of architecture in the en face plane, but, in addition, it provides morphologic information on the cellular level.1 The ability to visualize a lesion's primary morphologic features on multiple different levels has fueled new insights into the biological evolution of lesions. This month's Archives of Dermatology features an important article by Pellacani et al2 that correlates dermoscopic structures of melanocytic lesions with RCM and histopathologic analysis. This editorial, which is based on the findings reported by Pellacani et al2 and other correlation studies on dermoscopy, RCM, and histopathology,1,35 offers new theoretical insights into the biological progression of superficial spreading malignant melanoma (MM) by describing the concept of dermoepidermal junction (DEJ) remodeling. Although the remodeling concept remains speculative, we hope that it will spawn new research focused on elucidating the mechanisms involved in the growth and evolution of early MM.

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Figure 1.

Progression model of superficial spreading melanoma. A, Step 1 showing undulating dermoepidermal junction (DEJ) with preserved rete ridges that are infiltrated by confluent aggregates of melanoma cells. B, Step 2 showing a focus undergoing remodeling with flattening of the DEJ, associated with inflammation, angiogenesis, and fibroplasia. C, Step 3 showing an invasive tumor nodule arising adjacent to the area of remodeling.

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Figure 2.

Superficial spreading melanoma 0.35 mm in thickness showing mostly undulating dermoepidermal junction (DEJ). A, The lesion shows a reticular global dermoscopic pattern with peripheral streaks. B, Reflectance confocal microscopy (RCM) mosaic (1.5 × 1.5 mm) at the level of the DEJ (corresponding to the area within the square in A) showing preserved dermal papillae (DP; yellow asterisks) and rete ridges (RRs) widened by aggregated melanocytes (junctional thickening) and single melanocytes. C, RCM (0.5 × 0.5 mm) of dermoscopically identified streaks shows junctional thickening on RRs (white arrows) and preserved DP (yellow asterisks). Interestingly, the junctional aggregates expand peripherally over the RR meshwork and do not obliterate the DP (white arrows). D, Histopathologic analysis (hematoxylin-eosin, original magnification ×200) showing an undulating DEJ with DP (yellow asterisks) and RRs at the periphery of the lesion, and junctional aggregates of melanocytes at the bases of the RRs (white arrows).

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Figure 3.

Superficial spreading melanoma 0.5 mm in thickness showing focal flattening of the dermoepidermal junction (DEJ). A, On the dermoscopic image, the lesion shows a central blue-white structure (BWS) and peripheral fragmented network. B, Reflectance confocal microscopy (RCM) mosaic (2 × 2 mm) at the level of the DEJ (corresponding to the area within the square in A) showing in the area with dermoscopically identified network fragments, visible dermal papillae (DP) (yellow asterisks), and rete ridge (RR) meshwork pattern, which suggests an undulating DEJ. By contrast, in the BWS area, RCM shows thickened collagen with loss of the RR meshwork and DP (black asterisks). C, Corresponding histopathologic analysis (hematoxylin-eosin, original magnification ×40) shows an area with confluent aggregates of melanocytes at the tips of preserved RR (black arrow) and an area with discohesive aggregates of melanocytes at the base of a flat DEJ (dashed black arrow). The inflammatory infiltrate is more notable in the dermis under the flat DEJ. D, In the area with BWSs, an RCM individual image (0.5 × 0.5 mm) at the level of the basal layer of the epidermis shows irregular, confluent aggregates of melanocytes (yellow arrows) and individual nucleated melanocytes (white arrow) with no visible DP.

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Figure 4.

Superficial spreading melanoma 0.8 mm in thickness. A, Dermoscopy shows a multicomponent pattern with focal peripheral network (white arrow), area with flat blue-white structure (BWS) (yellow arrow), and an area with palpable BWS (blue-white veil, white asterisk). B, Scanning magnification histopathologic analysis (hematoxylin-eosin, original magnification ×40) shows an area in which dermoepidermal junction (DEJ) undulation is relatively preserved (black arrow) and an area with flat DEJ (dashed black arrow); the dermis underlying the flat DEJ shows more inflammation. C, Higher magnification histopathologic analysis (hematoxylin-eosin, original magnification ×200) showing junctional aggregates of melanocytes distending the rete ridges (black arrow); the dermal papillae can be seen in this area (black asterisk). D, Higher magnification histopathologic analysis (hematoxylin-eosin, original magnification ×200) showing junctional aggregates of melanocytes in a flat DEJ (black dashed arrow). E, Higher magnification histopathologic analysis (hematoxylin-eosin, original magnification ×200) showing flat DEJ and dense proliferation of melanocytes in the papillary dermis. C-E correspond to the 3 stages of the model, respectively.

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