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lichenoid keratosis&#44; actinic keratosis &#40;above all&#44; the pigmented variety&#41;&#44; Bowen disease&#44; and pigmented basal cell epitheliomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Reflectance confocal microscopy &#40;RCM&#41; is a noninvasive imaging technique that permits visualization of the epidermis and papillary dermis with a cellular resolution approaching that of conventional histology&#46; RCM is an excellent technique for analyzing and establishing diagnosis of facial lesions&#46; This article describes the main features of confocal microscopy images associated with diagnosis of LM&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical&#44; Histological&#44; and Dermoscopic Features of Lentigo Maligna</span><p id="par0020" class="elsevierStylePara elsevierViewall">LM is characterized clinically by the presence of slow-growing pigmented macules&#46; Differential diagnosis with solar lentigines&#44; pigmented actinic keratosis&#44; and flat seborrheic keratosis is sometimes complex&#46; It is much easier to distinguish LM from melanocytic nevi on the face given that&#44; in elderly individuals&#44; these latter lesions often have a papular appearance&#44; with normal skin coloration &#40;Miescher nevus&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histologically&#44; differential diagnosis between LM lesions and atypical melanocytic hyperplasia associated with sun-damaged skin may also be difficult&#44; particularly when only small biopsy samples are available&#46; A good pathologic-clinical correlation is essential for avoid wrong diagnosis&#44; particularly in areas of sun-damaged skin such as the face and neck in elderly individuals and in large lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> If LM is suspected on clinical grounds and the pathologic diagnosis is of junctional nevus&#44; dysplastic nevus&#44; or atypical lentiginous nevus&#44; the pathology findings should be reviewed in detail&#46; Furthermore&#44; surgery is usually complicated as these are large lesions with poorly defined borders on the face&#46; With amelanotic forms&#44; recurrence is not uncommon&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Dermoscopy is a technique that increases the sensitivity and specificity of diagnosis of pigmented facial lesions&#46; The classic dermoscopic features associated with LM were described by Schiffner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> in 2002 and include asymmetric follicular pigmentation&#44; presence of small slate-gray dots and globules irregularly distributed around the follicle &#40;annular-granular pattern&#41;&#44; pigmented rhomboidal structures&#44; and homogeneous areas that obliterate the follicles&#46; Actinic pigmented keratosis&#44; SL&#44; and lichenoid keratosis can also present an annular-granular pattern &#40;grey dots&#47;globules&#41;&#46; The rhomboidal structures and&#44; above all&#44; the homogeneous areas that obliterate the follicles are more specific to LM and are mainly associated with LM that have become invasive&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2012&#44; Pralong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> published the characteristics of 125 LM&#47;LMM lesions in white patients&#44; and verified the utility of the classic signs of LM&#46; They also identified additional dermoscopic signs associated with LM&#46; These included increased vascular density in the region of LM compared to surrounding skin&#44; presence of red rhomboidal structures&#44; presence of bullseye structures&#44; and darkening of the lesion on examination with dermoscopy compared to the clinical examination&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The increased vascular density and red rhomboidal structures can also be seen in actinic keratosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The angular or zigzag lines described in LM correspond to the early stages of formation of rhomboidal structures&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> In some extrafacial LM&#44; the only dermoscopic sign may be these zigzag lines&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> The presence of fine dots similar to those seen in the annular-granular pattern&#44; but of brown color and with nonannular distribution&#44; has been associated with failure of radiotherapy or imiquimod treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Confocal Reflectance Microscopy Features of Lentigo Maligna</span><p id="par0050" class="elsevierStylePara elsevierViewall">RCM is a noninvasive imaging technique that permits visualization of the epidermis and papillary dermis with a cellular resolution approaching that of conventional histology&#46; Both clinical and dermoscopic differential diagnosis of macular facial lesions such as SL&#44; seborrheic keratosis&#44; actinic keratosis&#44; Bowen disease&#44; basal cell epithelioma&#44; and LM is sometimes difficult&#46; In these cases&#44; RCM is very useful for establishing the correct diagnosis&#46; Most of the changes in LM are located in the epidermis and the dermal-epidermal junction&#46; RCM permits a precise visualization of the architectural and cytologic features typical of LM because images are obtained from the epidermis to the papillary dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> In addition to diagnosis&#44; RCM can also be used to define the margins of LM prior to treatment<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#8211;14</span></a> as well as during surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; RCM can detect recurrence after surgery or be used to assess response to nonsurgical treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">10&#44;12&#44;16&#44;17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A focal or global loss of honeycomb architecture is detected by RCM in the epidermis of LM lesions&#46; Atypical cells corresponding to pagetoid cell infiltration in histology are also observed&#46; The cells present are mainly of dendritic morphology &#40;large and pleomorphic cells with prominent dendrites&#41; and very indicative of LM if they are more than twice the size of keratinocytes&#44; abundant and atypical&#44; and located around follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Pagetoid cells can also be round&#44; large&#44; and atypical&#44; with evident nuclei&#46; Round cells occur less frequently than dendritic cells in LM but if they measure more than 20<span class="elsevierStyleHsp" style=""></span>&#956;m they are more specific&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A loss of the annular pattern at the dermal-epidermal junction is a common finding&#46; The presence of poorly delineated papillae with atypical cells is very indicative of LM&#46; It is necessary to differentiate between failure to visualize papillae characteristic of the facial site and the presence of papillae with poorly defined edges&#46; Dendritic cells at the dermal-epidermal junction can form bridges that resemble mitochondria&#46; These structures are frequently observed in melanomas in situ &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> Junctional thickening with atypical cells can also be found in LM&#46; This junctional thickening can be located radially around follicles&#44; giving them a tentacle-like appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>d&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19&#44;20</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Atypical nucleated cells can occasionally be observed in the dermis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">With RCM&#44; we can distinguish between LM and SL&#44; which is the main entity to be included in the differential diagnosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In SL&#44; the main findings are located in the dermal-epidermal junction&#44; as the changes are observed in the papillary dermis and rete ridges&#46; There is an increase in the density of the dermal papillae that presents as bright contours in a polycyclic shape &#40;papillae with polycyclic outline&#41;&#46; These contours are also known as bulbous projections and are formed by monomorphic&#44; brilliant&#44; reflective cells without atypia&#44; which contain melanin and melanosomes&#46; The contours seen by RCM correspond in dermoscopy to the fingerprint&#46; In the granular and spinous layer&#44; SL lesions maintain the honeycomb pattern consisting of monomorphic polygonal cells with a dark nucleus and clear cytoplasm&#44; and melanophages and lymphocytes can be seen in the dermal papillae&#46; The honeycomb pattern is lost focally or globally in LM lesions&#46; LM lesions also often show atypical pagetoid cells with a dendritic appearance with folliculotropism as well as loss of papillae and nonhomogeneous junction thickening with atypical cells&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">RCM also permits diagnosis of lichenoid keratosis&#46; Clinically&#44; this condition presents as macular lesions which&#44; in dermoscopic images&#44; show blue-grey regression distributed throughout the lesion&#46; With RCM&#44; pagetoid cells and cellular atypia are not observed&#46; These are abundant plump bright cells that sometimes cluster together and that correspond to melanophages&#44; usually without a visible nucleus&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In 2010&#44; Guitera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> published a prospective study analyzing 64 signs observed in RCM in hard-to-diagnose facial lesions &#40;81 LM lesions and 203 benign lesions were included&#41;&#46; They described the confocal features of the LM lesions&#44; and identified 6 parameters that were related to diagnosis of LM and established a diagnostic algorithm&#46; This included 2 major criteria&#44; each of which score &#43;2 points&#44; and 4 minor criteria&#44; 3 of which scored &#43;1 point and 1&#44; a negative criterion that protected diagnosis of LM&#44; scored -1&#46; The major criteria included loss of reflectance annular pattern typical of the dermal-epidermal junction and the presence of round pagetoid cells measuring more than 20 microns across&#46; The positive minor criteria were presence of 3 or more atypical cells in 5 quadrants of 0&#46;5 by 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm at the dermal-epidermal junction&#44; follicular localization of atypical cells&#44; and the finding of nucleated cells with the dermal papillae&#46; The negative criterion included presence of broadened epidermal pattern&#46; A score of 2 or more gave a sensitivity of 85&#37; and a specificity of 76&#37; for the diagnosis of LM &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">De Carvalho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> retrospectively analyzed 60 pigmented macular facial lesions&#44; including LM&#44; LMM&#44; SL&#47;planar seborrheic keratosis&#44; lichenoid keratosis&#44; and pigmented actinic keratosis&#46; Relating the dermoscopic features with RCM findings&#44; they found that the fingerprint pattern was only found in benign lesions and corresponded in RCM to polycyclic papillary contours&#46; The annular-granular pattern was present in both benign lesions and LM lesions&#46; The blue and black rhomboid structures and the blue or black spots were seen almost exclusively in LM&#47;LMM&#44; and above all in nonincipient lesions&#46; In a limited number of cases of benign lesions with spots or homogenous areas&#44; the lesions corresponded to a cobblestone pattern in the epidermis and papillary polycyclic contours consisting of basal hyperpigmented cells located at the dermal-epidermal junction&#44; typical of SL lesions and planar seborrheic keratosis&#46; In LM&#47;LMM&#44; intraepidermal proliferation of dendritic cells was observed &#40;a rare finding in benign lesions&#41; with a tendency towards folliculotropism&#46; In addition&#44; the authors found junctional thickening comprised of atypical cells that were located radially around the follicles&#44; adopting a tentacle-like appearance&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The utility of RCM in the follow-up of noninvasive treatments of LM was studied by Guitera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> in 99 patients diagnosed with LM who had been treated with radiotherapy or imiquimod&#46; Dermoscopy had a sensitivity of 80&#37; and a specificity of 56&#37;&#44; whereas applying the diagnostic algorithm for LM with RCM&#44; the specificity was 94&#37; and the sensitivity 100&#37;&#46; The 2 dermoscopic signs that were most closely associated with histologic diagnosis of melanoma were asymmetric follicular openings and the presence of fine brown dots &#40;similar to the dotted annular-granular pattern but without the annular distribution&#41;&#46; This brown dotted pattern corresponded to the RCM finding of pagetoid cells&#44; unlike the fine greyish points&#44; which appeared as melanophages in RCM&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">RCM is a very effective technique for the diagnosis of LM&#46; The presence of atypical cells in the epidermis &#40;with predominantly perifollicular localization&#41; or the dermal-epidermal junction&#44; as well as loss of normal skin architecture in the epidermal and dermal-epidermal junction are key for diagnosis of LM&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">RCM permits us to analyze the entire surface of the lesion&#44; as well as correlate findings with dermoscopic characteristics&#46; RCM is an excellent technique for choosing areas to biopsy&#46; It can delineate the margins of the lesion &#40;even amelanotic lesions&#41; and enable assessment of response to treatment and detection of recurrences in a noninvasive fashion&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We therefore believe that RCM is key not only in the diagnosis but also in the follow-up of LM&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Clinical&#44; Histological&#44; and Dermoscopic Features of Lentigo Maligna"
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          "titulo" => "Confocal Reflectance Microscopy Features of Lentigo Maligna"
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          "titulo" => "Conclusions"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna is the most common type of facial melanoma&#46; Diagnosis is complicated&#44; however&#44; as it shares clinical and dermoscopic characteristics with other cutaneous lesions of the face&#46; Reflectance confocal microscopy is an imaging technique that permits the visualization of characteristic features of lentigo maligna&#46; These include a disrupted honeycomb pattern and pagetoid cells with a tendency to show folliculotropism&#46; These cells typically have a dendritic morphology&#44; although they may also appear as round cells measuring over 20<span class="elsevierStyleHsp" style=""></span>&#956;m with atypical nuclei&#46; Poorly defined dermal papillae and atypical cells may be seen at the dermal-epidermal junction and can form bridges resembling mitochondrial structures&#46; Other characteristic findings include junctional swelling with atypical cells located around the follicles&#44; resembling caput medusae&#46; Reflectance confocal microscopy is a very useful tool for diagnosing lentigo maligna&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El lentigo maligno es el melanoma m&#225;s frecuente en la cara&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico del lentigo maligno es complicado porque los signos cl&#237;nicos y dermatosc&#243;picos asociados a lentigo maligno pueden verse en otras lesiones cut&#225;neas faciales&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La microscopia confocal de reflectancia es una t&#233;cnica de imagen que permite detectar hallazgos caracter&#237;sticos del lentigo maligno&#46; En la epidermis encontramos la p&#233;rdida del patr&#243;n en panal de abejas y c&#233;lulas pagetoides con tendencia al foliculotropismo&#46; Estas c&#233;lulas pagetoides suelen ser de morfolog&#237;a dendr&#237;tica&#44; aunque tambi&#233;n pueden presentarse como c&#233;lulas redondas mayores de 20<span class="elsevierStyleHsp" style=""></span>&#956;m con n&#250;cleos at&#237;picos&#46; En la uni&#243;n dermoepid&#233;rmica las papilas d&#233;rmicas pueden estar mal delimitadas y haber c&#233;lulas at&#237;picas&#46; Estas c&#233;lulas pueden formar puentes que parecen estructuras mitocondriales&#46; Adem&#225;s&#44; podemos ver engrosamientos junturales con c&#233;lulas at&#237;picas localizados alrededor de los fol&#237;culos simulando una cabeza de medusa&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La microscopia confocal de reflectancia es muy &#250;til en el diagn&#243;stico del lentigo maligno&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gamo R&#44; Pamp&#237;n A&#44; Florist&#225;n U&#46; La microscop&#237;a confocal de reflectancia en el lentigo maligno&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;830&#8211;835&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A&#44; Facial polychrome macule of 3 years duration on a 68-year-old man&#46; B&#44; Dermoscopic image with asymmetric follicular openings &#40;yellow arrow&#41;&#44; increased vascular density &#40;yellow square&#41;&#44; and brown rhomboid structures &#40;blue arrow&#41;&#46; C&#44; RCM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mm black square in the dermoscopic image&#44; showing abundant dendritic cells &#40;yellow square&#41; with follicular localization&#46; To the left of the image&#44; loss of the honeycomb pattern is observed in the spinous cell layer&#59; to the right&#44; the image corresponds to the horny layer&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A&#44; Clinical image showing a pigmented lesion on an 80-year-old man&#46; B&#44; Dermoscopic lesion with abundant blue-gray rhomboid structures &#40;yellow arrows&#41; and vascularization &#40;blue arrow&#41;&#46; C&#44; CRM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm black box in the dermoscopic image&#44; showing the dermal-epidermal junction broadening with atypical cells &#40;yellow arrows&#41;&#59; the localization of the dendritic cells&#44; forming bridges that constitute the structures that simulate mitochondria &#40;blue arrows&#41; can also be seen&#46; D&#44; CRM image of 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm in which their follicular localization can be seen with a tentacle-like appearance &#40;yellow box&#41;&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A&#44; Dermoscopic image of a lesion of 3 years duration on the cheek of a 72-year-old woman&#46; Dark brown rhomboidal structures are observed on a large part of the lesion &#40;yellow arrows&#41;&#46; B&#44; CRM image showing irregular junction broadening with atypical cells &#40;yellow arrows&#41;&#46; C&#44; Dermoscopic image of a supraciliary lesion of 10 years duration in a 50-year-old woman&#46; Asymmetric follicular pigmentation &#40;yellow arrows&#41; can be observed&#46; D&#44; CRM image showing areas &#40;yellow boxes&#41; with an increased density of dermal papillae with polycyclic and geometric outlines that are named polycyclic papillary contours &#40;also known as bulbous projections&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A score of more than 2 has a sensitivity of 85&#37; and a specificity of 76&#37; for the diagnosis of LM&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Major Features<br>&#40;score &#43;2 points&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Nonedged papillae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pagetoid cells&#44; round and greater than 20<span class="elsevierStyleHsp" style=""></span>&#956;m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Positive minor features<br>&#40;score &#43;1 point&#41;</td><td class="td" title="table-entry  " align="left" valign="top">More than 3 atypical cells at the junction in 5 images&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follicular localization of pagetoid cells and&#47;or atypical junctional cells&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nucleated cells within the papilla&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative minor feature<br>&#40;score -1 point&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broadened honeycomb pattern&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Algorithm of Lentigo Maligna of Guitera et al<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p>"
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    "bibliografia" => array:2 [
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      "seccion" => array:1 [
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            0 => array:3 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lentigo maligna and lentigo maligna melanoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46;M&#46; Cohen"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "1995"
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Practical Dermatology
Reflectance Confocal Microscopy in Lentigo Maligna
La microscopía confocal de reflectancia en el lentigo maligno
R. Gamo
Autor para correspondencia
reyesgamo2000@yahoo.es

Corresponding author.
, A. Pampín, U. Floristán
Hospital Universitario Fundación de Alcorcón, Madrid, Spain
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        "titulo" => "La microscop&#237;a confocal de reflectancia en el lentigo maligno"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A&#44; Clinical image showing a pigmented lesion on an 80-year-old man&#46; B&#44; Dermoscopic lesion with abundant blue-gray rhomboid structures &#40;yellow arrows&#41; and vascularization &#40;blue arrow&#41;&#46; C&#44; CRM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm black box in the dermoscopic image&#44; showing the dermal-epidermal junction broadening with atypical cells &#40;yellow arrows&#41;&#59; the localization of the dendritic cells&#44; forming bridges that constitute the structures that simulate mitochondria &#40;blue arrows&#41; can also be seen&#46; D&#44; CRM image of 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm in which their follicular localization can be seen with a tentacle-like appearance &#40;yellow box&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lentigo maligna &#40;LM&#41; is a melanoma in situ that usually presents on sun-exposed skin &#40;head and neck&#41; in elderly individuals&#46; LM accounts for 80&#37; of melanomas in situ and is the most common facial melanoma&#46; If the lesion becomes invasive&#44; it is termed LM melanoma &#40;LMM&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnosis of LM is difficult because the initial clinical and dermoscopic signs are subtle and not pathognomonic&#46; In addition&#44; differential diagnosis needs to include numerous pigmented lesions&#44; such as solar lentigines &#40;SL&#41;&#44; simple lentigines&#44; flat seborrheic keratosis &#40;irritated or not irritated&#41;&#44; lichenoid keratosis&#44; actinic keratosis &#40;above all&#44; the pigmented variety&#41;&#44; Bowen disease&#44; and pigmented basal cell epitheliomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Reflectance confocal microscopy &#40;RCM&#41; is a noninvasive imaging technique that permits visualization of the epidermis and papillary dermis with a cellular resolution approaching that of conventional histology&#46; RCM is an excellent technique for analyzing and establishing diagnosis of facial lesions&#46; This article describes the main features of confocal microscopy images associated with diagnosis of LM&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical&#44; Histological&#44; and Dermoscopic Features of Lentigo Maligna</span><p id="par0020" class="elsevierStylePara elsevierViewall">LM is characterized clinically by the presence of slow-growing pigmented macules&#46; Differential diagnosis with solar lentigines&#44; pigmented actinic keratosis&#44; and flat seborrheic keratosis is sometimes complex&#46; It is much easier to distinguish LM from melanocytic nevi on the face given that&#44; in elderly individuals&#44; these latter lesions often have a papular appearance&#44; with normal skin coloration &#40;Miescher nevus&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histologically&#44; differential diagnosis between LM lesions and atypical melanocytic hyperplasia associated with sun-damaged skin may also be difficult&#44; particularly when only small biopsy samples are available&#46; A good pathologic-clinical correlation is essential for avoid wrong diagnosis&#44; particularly in areas of sun-damaged skin such as the face and neck in elderly individuals and in large lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> If LM is suspected on clinical grounds and the pathologic diagnosis is of junctional nevus&#44; dysplastic nevus&#44; or atypical lentiginous nevus&#44; the pathology findings should be reviewed in detail&#46; Furthermore&#44; surgery is usually complicated as these are large lesions with poorly defined borders on the face&#46; With amelanotic forms&#44; recurrence is not uncommon&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Dermoscopy is a technique that increases the sensitivity and specificity of diagnosis of pigmented facial lesions&#46; The classic dermoscopic features associated with LM were described by Schiffner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> in 2002 and include asymmetric follicular pigmentation&#44; presence of small slate-gray dots and globules irregularly distributed around the follicle &#40;annular-granular pattern&#41;&#44; pigmented rhomboidal structures&#44; and homogeneous areas that obliterate the follicles&#46; Actinic pigmented keratosis&#44; SL&#44; and lichenoid keratosis can also present an annular-granular pattern &#40;grey dots&#47;globules&#41;&#46; The rhomboidal structures and&#44; above all&#44; the homogeneous areas that obliterate the follicles are more specific to LM and are mainly associated with LM that have become invasive&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2012&#44; Pralong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> published the characteristics of 125 LM&#47;LMM lesions in white patients&#44; and verified the utility of the classic signs of LM&#46; They also identified additional dermoscopic signs associated with LM&#46; These included increased vascular density in the region of LM compared to surrounding skin&#44; presence of red rhomboidal structures&#44; presence of bullseye structures&#44; and darkening of the lesion on examination with dermoscopy compared to the clinical examination&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The increased vascular density and red rhomboidal structures can also be seen in actinic keratosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The angular or zigzag lines described in LM correspond to the early stages of formation of rhomboidal structures&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> In some extrafacial LM&#44; the only dermoscopic sign may be these zigzag lines&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> The presence of fine dots similar to those seen in the annular-granular pattern&#44; but of brown color and with nonannular distribution&#44; has been associated with failure of radiotherapy or imiquimod treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Confocal Reflectance Microscopy Features of Lentigo Maligna</span><p id="par0050" class="elsevierStylePara elsevierViewall">RCM is a noninvasive imaging technique that permits visualization of the epidermis and papillary dermis with a cellular resolution approaching that of conventional histology&#46; Both clinical and dermoscopic differential diagnosis of macular facial lesions such as SL&#44; seborrheic keratosis&#44; actinic keratosis&#44; Bowen disease&#44; basal cell epithelioma&#44; and LM is sometimes difficult&#46; In these cases&#44; RCM is very useful for establishing the correct diagnosis&#46; Most of the changes in LM are located in the epidermis and the dermal-epidermal junction&#46; RCM permits a precise visualization of the architectural and cytologic features typical of LM because images are obtained from the epidermis to the papillary dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> In addition to diagnosis&#44; RCM can also be used to define the margins of LM prior to treatment<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#8211;14</span></a> as well as during surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; RCM can detect recurrence after surgery or be used to assess response to nonsurgical treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">10&#44;12&#44;16&#44;17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A focal or global loss of honeycomb architecture is detected by RCM in the epidermis of LM lesions&#46; Atypical cells corresponding to pagetoid cell infiltration in histology are also observed&#46; The cells present are mainly of dendritic morphology &#40;large and pleomorphic cells with prominent dendrites&#41; and very indicative of LM if they are more than twice the size of keratinocytes&#44; abundant and atypical&#44; and located around follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Pagetoid cells can also be round&#44; large&#44; and atypical&#44; with evident nuclei&#46; Round cells occur less frequently than dendritic cells in LM but if they measure more than 20<span class="elsevierStyleHsp" style=""></span>&#956;m they are more specific&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A loss of the annular pattern at the dermal-epidermal junction is a common finding&#46; The presence of poorly delineated papillae with atypical cells is very indicative of LM&#46; It is necessary to differentiate between failure to visualize papillae characteristic of the facial site and the presence of papillae with poorly defined edges&#46; Dendritic cells at the dermal-epidermal junction can form bridges that resemble mitochondria&#46; These structures are frequently observed in melanomas in situ &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> Junctional thickening with atypical cells can also be found in LM&#46; This junctional thickening can be located radially around follicles&#44; giving them a tentacle-like appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>d&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19&#44;20</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Atypical nucleated cells can occasionally be observed in the dermis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">With RCM&#44; we can distinguish between LM and SL&#44; which is the main entity to be included in the differential diagnosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In SL&#44; the main findings are located in the dermal-epidermal junction&#44; as the changes are observed in the papillary dermis and rete ridges&#46; There is an increase in the density of the dermal papillae that presents as bright contours in a polycyclic shape &#40;papillae with polycyclic outline&#41;&#46; These contours are also known as bulbous projections and are formed by monomorphic&#44; brilliant&#44; reflective cells without atypia&#44; which contain melanin and melanosomes&#46; The contours seen by RCM correspond in dermoscopy to the fingerprint&#46; In the granular and spinous layer&#44; SL lesions maintain the honeycomb pattern consisting of monomorphic polygonal cells with a dark nucleus and clear cytoplasm&#44; and melanophages and lymphocytes can be seen in the dermal papillae&#46; The honeycomb pattern is lost focally or globally in LM lesions&#46; LM lesions also often show atypical pagetoid cells with a dendritic appearance with folliculotropism as well as loss of papillae and nonhomogeneous junction thickening with atypical cells&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">RCM also permits diagnosis of lichenoid keratosis&#46; Clinically&#44; this condition presents as macular lesions which&#44; in dermoscopic images&#44; show blue-grey regression distributed throughout the lesion&#46; With RCM&#44; pagetoid cells and cellular atypia are not observed&#46; These are abundant plump bright cells that sometimes cluster together and that correspond to melanophages&#44; usually without a visible nucleus&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In 2010&#44; Guitera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> published a prospective study analyzing 64 signs observed in RCM in hard-to-diagnose facial lesions &#40;81 LM lesions and 203 benign lesions were included&#41;&#46; They described the confocal features of the LM lesions&#44; and identified 6 parameters that were related to diagnosis of LM and established a diagnostic algorithm&#46; This included 2 major criteria&#44; each of which score &#43;2 points&#44; and 4 minor criteria&#44; 3 of which scored &#43;1 point and 1&#44; a negative criterion that protected diagnosis of LM&#44; scored -1&#46; The major criteria included loss of reflectance annular pattern typical of the dermal-epidermal junction and the presence of round pagetoid cells measuring more than 20 microns across&#46; The positive minor criteria were presence of 3 or more atypical cells in 5 quadrants of 0&#46;5 by 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm at the dermal-epidermal junction&#44; follicular localization of atypical cells&#44; and the finding of nucleated cells with the dermal papillae&#46; The negative criterion included presence of broadened epidermal pattern&#46; A score of 2 or more gave a sensitivity of 85&#37; and a specificity of 76&#37; for the diagnosis of LM &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">De Carvalho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> retrospectively analyzed 60 pigmented macular facial lesions&#44; including LM&#44; LMM&#44; SL&#47;planar seborrheic keratosis&#44; lichenoid keratosis&#44; and pigmented actinic keratosis&#46; Relating the dermoscopic features with RCM findings&#44; they found that the fingerprint pattern was only found in benign lesions and corresponded in RCM to polycyclic papillary contours&#46; The annular-granular pattern was present in both benign lesions and LM lesions&#46; The blue and black rhomboid structures and the blue or black spots were seen almost exclusively in LM&#47;LMM&#44; and above all in nonincipient lesions&#46; In a limited number of cases of benign lesions with spots or homogenous areas&#44; the lesions corresponded to a cobblestone pattern in the epidermis and papillary polycyclic contours consisting of basal hyperpigmented cells located at the dermal-epidermal junction&#44; typical of SL lesions and planar seborrheic keratosis&#46; In LM&#47;LMM&#44; intraepidermal proliferation of dendritic cells was observed &#40;a rare finding in benign lesions&#41; with a tendency towards folliculotropism&#46; In addition&#44; the authors found junctional thickening comprised of atypical cells that were located radially around the follicles&#44; adopting a tentacle-like appearance&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The utility of RCM in the follow-up of noninvasive treatments of LM was studied by Guitera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> in 99 patients diagnosed with LM who had been treated with radiotherapy or imiquimod&#46; Dermoscopy had a sensitivity of 80&#37; and a specificity of 56&#37;&#44; whereas applying the diagnostic algorithm for LM with RCM&#44; the specificity was 94&#37; and the sensitivity 100&#37;&#46; The 2 dermoscopic signs that were most closely associated with histologic diagnosis of melanoma were asymmetric follicular openings and the presence of fine brown dots &#40;similar to the dotted annular-granular pattern but without the annular distribution&#41;&#46; This brown dotted pattern corresponded to the RCM finding of pagetoid cells&#44; unlike the fine greyish points&#44; which appeared as melanophages in RCM&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">RCM is a very effective technique for the diagnosis of LM&#46; The presence of atypical cells in the epidermis &#40;with predominantly perifollicular localization&#41; or the dermal-epidermal junction&#44; as well as loss of normal skin architecture in the epidermal and dermal-epidermal junction are key for diagnosis of LM&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">RCM permits us to analyze the entire surface of the lesion&#44; as well as correlate findings with dermoscopic characteristics&#46; RCM is an excellent technique for choosing areas to biopsy&#46; It can delineate the margins of the lesion &#40;even amelanotic lesions&#41; and enable assessment of response to treatment and detection of recurrences in a noninvasive fashion&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We therefore believe that RCM is key not only in the diagnosis but also in the follow-up of LM&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna is the most common type of facial melanoma&#46; Diagnosis is complicated&#44; however&#44; as it shares clinical and dermoscopic characteristics with other cutaneous lesions of the face&#46; Reflectance confocal microscopy is an imaging technique that permits the visualization of characteristic features of lentigo maligna&#46; These include a disrupted honeycomb pattern and pagetoid cells with a tendency to show folliculotropism&#46; These cells typically have a dendritic morphology&#44; although they may also appear as round cells measuring over 20<span class="elsevierStyleHsp" style=""></span>&#956;m with atypical nuclei&#46; Poorly defined dermal papillae and atypical cells may be seen at the dermal-epidermal junction and can form bridges resembling mitochondrial structures&#46; Other characteristic findings include junctional swelling with atypical cells located around the follicles&#44; resembling caput medusae&#46; Reflectance confocal microscopy is a very useful tool for diagnosing lentigo maligna&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El lentigo maligno es el melanoma m&#225;s frecuente en la cara&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico del lentigo maligno es complicado porque los signos cl&#237;nicos y dermatosc&#243;picos asociados a lentigo maligno pueden verse en otras lesiones cut&#225;neas faciales&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La microscopia confocal de reflectancia es una t&#233;cnica de imagen que permite detectar hallazgos caracter&#237;sticos del lentigo maligno&#46; En la epidermis encontramos la p&#233;rdida del patr&#243;n en panal de abejas y c&#233;lulas pagetoides con tendencia al foliculotropismo&#46; Estas c&#233;lulas pagetoides suelen ser de morfolog&#237;a dendr&#237;tica&#44; aunque tambi&#233;n pueden presentarse como c&#233;lulas redondas mayores de 20<span class="elsevierStyleHsp" style=""></span>&#956;m con n&#250;cleos at&#237;picos&#46; En la uni&#243;n dermoepid&#233;rmica las papilas d&#233;rmicas pueden estar mal delimitadas y haber c&#233;lulas at&#237;picas&#46; Estas c&#233;lulas pueden formar puentes que parecen estructuras mitocondriales&#46; Adem&#225;s&#44; podemos ver engrosamientos junturales con c&#233;lulas at&#237;picas localizados alrededor de los fol&#237;culos simulando una cabeza de medusa&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La microscopia confocal de reflectancia es muy &#250;til en el diagn&#243;stico del lentigo maligno&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gamo R&#44; Pamp&#237;n A&#44; Florist&#225;n U&#46; La microscop&#237;a confocal de reflectancia en el lentigo maligno&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;830&#8211;835&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A&#44; Facial polychrome macule of 3 years duration on a 68-year-old man&#46; B&#44; Dermoscopic image with asymmetric follicular openings &#40;yellow arrow&#41;&#44; increased vascular density &#40;yellow square&#41;&#44; and brown rhomboid structures &#40;blue arrow&#41;&#46; C&#44; RCM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mm black square in the dermoscopic image&#44; showing abundant dendritic cells &#40;yellow square&#41; with follicular localization&#46; To the left of the image&#44; loss of the honeycomb pattern is observed in the spinous cell layer&#59; to the right&#44; the image corresponds to the horny layer&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A&#44; Clinical image showing a pigmented lesion on an 80-year-old man&#46; B&#44; Dermoscopic lesion with abundant blue-gray rhomboid structures &#40;yellow arrows&#41; and vascularization &#40;blue arrow&#41;&#46; C&#44; CRM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm black box in the dermoscopic image&#44; showing the dermal-epidermal junction broadening with atypical cells &#40;yellow arrows&#41;&#59; the localization of the dendritic cells&#44; forming bridges that constitute the structures that simulate mitochondria &#40;blue arrows&#41; can also be seen&#46; D&#44; CRM image of 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm in which their follicular localization can be seen with a tentacle-like appearance &#40;yellow box&#41;&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A&#44; Dermoscopic image of a lesion of 3 years duration on the cheek of a 72-year-old woman&#46; Dark brown rhomboidal structures are observed on a large part of the lesion &#40;yellow arrows&#41;&#46; B&#44; CRM image showing irregular junction broadening with atypical cells &#40;yellow arrows&#41;&#46; C&#44; Dermoscopic image of a supraciliary lesion of 10 years duration in a 50-year-old woman&#46; Asymmetric follicular pigmentation &#40;yellow arrows&#41; can be observed&#46; D&#44; CRM image showing areas &#40;yellow boxes&#41; with an increased density of dermal papillae with polycyclic and geometric outlines that are named polycyclic papillary contours &#40;also known as bulbous projections&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A score of more than 2 has a sensitivity of 85&#37; and a specificity of 76&#37; for the diagnosis of LM&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Major Features<br>&#40;score &#43;2 points&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Nonedged papillae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pagetoid cells&#44; round and greater than 20<span class="elsevierStyleHsp" style=""></span>&#956;m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Positive minor features<br>&#40;score &#43;1 point&#41;</td><td class="td" title="table-entry  " align="left" valign="top">More than 3 atypical cells at the junction in 5 images&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follicular localization of pagetoid cells and&#47;or atypical junctional cells&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nucleated cells within the papilla&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative minor feature<br>&#40;score -1 point&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broadened honeycomb pattern&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Algorithm of Lentigo Maligna of Guitera et al<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p>"
        ]
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