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To report a case of intraretinal tubercular granuloma successfully treated with photodynamic therapy (PDT).Retrospective case report. Multimodal imaging was performed at each follow-up visit.The tuberculoma did not regress and did not significantly reduce its exudation after anti-tubercular therapy (ATT), systemic steroid therapy and intravitreal anti-VEGF. Second line treatment with PDT was attempted. The lesion showed a regression with reduced sub-retinal fluid and intra-retinal exudates. A second PDT was performed for reactivation of the lesion 5 months after the first treatment. Further regression of the lesion was observed.PDT may be a valuable second-line therapeutic approach for vascularized intraretinal granulomas.

Differential diagnosis between a melanoma and a pseudomelanoma requires many years of experience and ocular studies, and requires paying attention to the smallest details. The case is presented of a 57 year-old male with an adenoma of the ciliary body pigment epithelium that was treated with an enucleation of the eye due to a suspicion of a choroidal melanoma.

Recurrent pigmentations on scars after melanocytic tumor excision can be confusing due to its similarities to melanoma. Meanwhile, these conditions which can be mixed with malignant conditions also cause difficulties in diagnosis. Herein, we present a melanoma case developed on a scar region after a while later compound nevus excision.

PURPOSE To illustrate a potentially concerning artifact on Optos wide-angle imaging. METHODS Case report. RESULTS A healthy 11-year-old girl, with no medical history, was found to have a lightly pigmented superotemporal choroidal tumor, suspicious for melanoma, which was detected on Optos wide-angle imaging by her optometrist. On referral to the retinal specialist, the mass was not visible on funduscopy. B-scan ultrasonography depicted flat retina and no visible mass. Review of the Optos image revealed that the pseudomelanoma represented the patient's nose. CONCLUSION Optos wide-angle imaging provides broad retinal imaging; however, artifacts from patient positioning can lead to the nose artifact.

We report the case of an adolescent girl that presented with an atypical melanocytic lesion on the left gluteal region, suspicious for melanoma. She was healthy with no associated diseases, and there was no history of skin cancer in the family. The nevus had been present for several years, but she had noted a change and growth of it in the last few months. She reported that the nevus was injured about 2 years earlier and it had appeared different ever since. Although dermoscopic examination showed the lesion to be highly suspicious for melanoma and it was therefore surgically excised on the same day, pathohistological examination showed a compound melanocytic nevus with extensive dermal fibrosis/regression and overlying atypical junctional hyperplasia of melanocytes consistent with pseudomelanoma, also known as recurrent melanocytic nevus.

Uveal melanoma is the most common intraocular malignancy in adults. Choroidal melanomas constitute around 90% of it. It is characterized by certain chromosomal alterations and genetic mutations. The diagnosis is mainly clinical. Characteristic findings have been noted on ultrasonography. The current treatment options include laser (photodynamic therapy, transpupillary thermotherapy), radiation therapy, and surgical resection. Prognosis depends on the size of the tumor. Almost half of the patients have risk of micro-metastasis within 10 years of diagnosis.

Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare retinal vasculopathy that might cause subretinal and/or vitreous hemorrhages. Although the primary etiology is still unknown, choroidal neovascularization is mainly involved in the pathogenesis. The main risk factors are age and systemic hypertension. Ancillary testing such as fluorescein angiography, indocyanine green angiography and ultrasonography can be of great value for diagnosing this entity and distinguishing PEHCR from other lesions as choroidal melanoma and retinal vasoproliferative tumor. Various treatments have been reported including photocoagulation, cryotherapy, intravitreal injection of anti-vascular endothelial growth factor (Anti-VEGF) and surgical intervention as pars plana vitrectomy. This review handles an up-to-date perspective regarding PEHCR.

Background: We report a case of suprachoroidal hemorrhage simulating choroidal melanoma in a patient with idiopathic thrombocytopenic purpura (ITP). Methods: Case report. Results: A 79-year-old white male with a history of lung adenocarcinoma, ITP, and mild anemia noted blurred vision with photopsia and floaters in the right eye (OD) that worsened over 2 months. He was found to have a pigmented choroidal mass and was referred for evaluation of possible choroidal melanoma. Visual acuity was 20/30 in the affected right eye and 20/25 in the left eye (OS). There was mild vitreous hemorrhage and 2 pigmented peripheral choroidal tumors in the temporal and nasal fundus OD. B-scan ultrasonography confirmed 2 acoustically hollow tumors, and transillumination demonstrated no shadowing. Optical coherence tomography over the lesions revealed choroidal elevation with suprachoroidal scalloped surface. Fluorescein and indocyanine green angiography revealed normal choroidal fluorescence and cyanescence with no “double circulation” of melanoma and no dye blockage, suggesting a suprachoroidal location. These findings were suggestive of suprachoroidal hemorrhage rather than melanoma. The patient was managed conservatively, and the hemorrhages demonstrated spontaneous resolution. Conclusion: Ocular manifestations of ITP are uncommon. Rarely, spontaneous suprachoroidal hemorrhage simulating melanoma can occur. A thorough clinical evaluation with multimodal imaging is critical to establishing the appropriate diagnosis.

Atypical acquired melanocytic nevi in patients with epidermolysis bullosa (EB) have been referred to as EB nevi and are considered to be a type of recurrent nevus with atypical but distinctive histopathologic findings. Herein, we describe an atypical nevus in a patient with Hailey-Hailey disease with different histopathologic findings from EB nevi because of presumably different pathogenesis. It is important to be aware that the recurrent nevi phenomenon can be seen in acantholytic conditions as well as blistering disorders, given these lesions may clinically resemble melanoma.

The recommended initial management for suspected melanoma is excisional biopsy. The use of partial biopsies of melanocytic tumours poses potential problems including misdiagnosis due to either unrepresentative sampling or the difficulty in evaluating important diagnostic features; an inaccurate assessment of Breslow thickness and other important prognostic features; and the induction of changes capable of mimicking melanoma (i.e., pseudomelanoma). Misdiagnosis, in turn, may lead to inappropriate management of the patient and an adverse outcome. In this report we document a previously unrecognised pitfall of partial biopsies of melanocytic tumours: implantation of tumour cells at the biopsy site potentially leading to the overestimation of tumour thickness or a misdiagnosis of the presence of microsatellites in the subsequent wide excision specimen.

Purpose: The purpose of the study was to investigate the corticosteroids for uveal effusion syndrome (UES). Methods: Retrospective series of 104 eyes with UES treated with oral corticosteroids (OCS), periocular corticosteroids (PCS), topical corticosteroids (TCS), or observation (OBS). Main outcome measure was UES resolution. Results: Of 104 eyes, treatment included OCS (n = 27), PCS (n = 12), TCS (n = 11), and OBS (n = 54). A comparison of the four groups (OCS vs. PCS vs. TCS vs. OBS) revealed differences in those managed with OCS versus OBS as younger (66 vs. 72 years, P = 0.049), PCS versus OBS as male (100% vs. 54%, P = 0.002), PCS versus OBS with decreased visual acuity (VA)/visual field (91% vs. 51%, P = 0.018), and OBS versus OCS as asymptomatic (28% vs. 0%, P = 0.001). Of the 59 with follow-up information, management included OCS (n = 21), PCS (n = 12), TCS (n = 6), and OBS (n = 20). There were differences in initial VA

In this report, we present a novel case of pseudomelanoma, similar to that seen in a recurrent/traumatized nevus, in pre-existing nevi in a 36-year-old man a few months after recovering from an episode of severe Stevens-Johnson syndrome. The mechanism responsible for the atypical transformation of these nevi is likely the release of cytokines and growth factors in the microenvironment during the repair/regeneration process. It is important to be aware of this phenomenon, and specific inquiry about potential recent blistering skin disorder in addition to the other causes of trauma should be made when dealing with cases of pseudomelanoma to avoid misdiagnosis.

Recurrent nevi are benign melanocytic nevi that regrow after incomplete surgical removal or traumatic injury. Recurrent nevi are biologically benign without a documented risk of malignant progression, but they pose diagnostic problems because their morphological features resemble those of melanoma. They are also commonly referred to as “pseudomelanomas.” The management of repigmentation within a scar after incomplete biopsy or other destructive procedures (i.e., laser and cryotherapy) depends on whether a prior histopathologic diagnosis confirming a benign tumor was obtained or not. In cases of regrowth without histopathologic diagnosis, immediate excision and histopathologic examination are mandatory to rule out melanoma unintentionally treated as benign tumor. When a prior histopathologic diagnosis reports a benign tumor, often no further interventions are performed. However, careful histologic reevaluation of the slides of the previous excision is strongly encouraged, in order to avoid a misclassification which potentially delays diagnosis and adequate treatment of recurrent melanoma. The differential diagnosis of newly developing pigmentation within a scar of a previous excision of a melanocytic lesion includes recurrent nevus, recurrent melanoma, and melanotic reactive pigmentation. As a general rule, a relatively rapid development of the repigmentation favors the diagnosis of a benign recurrence. This is confined within the scar, and, dermoscopically, a regularly pigmented network and thin parallel streaks are associated with reactive pigmentations, whereas an irregular prominent network, globules, streaks, and heterogeneous pigmentation are usually associated with a melanocytic proliferation. On the other side, melanomas tend to recur months if not years after excision at the edges of the scar in the normal skin. Dermoscopy may not reveal specific melanoma features, displaying only a heterogeneous, structureless pigmentation. Therefore, in the case of a recurrent pigmentation involving the normal skin around the scar, a biopsy specimen should be obtained to exclude a possible melanoma recurrence. Histological features, even in case of recurrent nevi, can be very worrisome as recurrent nevi generally present a rich junctional component, sometimes frankly atypical and, with epidermotropism, arising on a sclerotic dermis.

We present a case of a 6-year-old girl with recessive dystrophic epidermolysis bullosa (EB) who presented with a large pigmented lesion clinically concerning for melanoma. After histological examination and fluorescent in situ hybridization analysis, diagnosis of EB nevus was performed. EB nevi are benign melanocytic neoplasms with histological findings similar to recurrent nevi occurring in all types of EB. They often mimic melanoma clinically, dermatoscopically, and histopathologically. The ability to recognize an EB nevus is essential for appropriate management of the patient. Unnecessary surgical excision in patients with already high-risk EB should be avoided. Close monitoring of these lesions is recommended because no cases of transformation to melanoma have been described.

To review the current features and classification of choroidal melanoma, and to identify the lesions that clinically simulate choroidal melanoma (pseudomelanoma).Uveal melanoma is a serious life-threatening intraocular malignancy, most often found in Caucasians (98%) and primarily involving the choroid (90%), ciliary body (7%), or iris (2%). This review will concentrate on choroidal melanoma. At diagnosis, choroidal melanoma usually appears as a pigmented (85%) tumor underlying the retina with a median basal dimension of 11 mm and a mean thickness of 4.5 mm. The American Joint Committee on Cancer classification allows for categorization and staging of melanoma. Following ocular therapy, adjuvant systemic therapy is provided for patients with high-risk melanoma who demonstrate alterations in chromosomes 3, 6, and 8 or those with class 2 on gene-expression profiling, detected by needle biopsy or solid tumor biopsy. The prognosis of choroidal melanoma depends most importantly on the genetic alterations and tumor size. Every millimeter increase in thickness leads to a 5% increased risk for metastasis. The leading conditions that simulate choroidal melanoma include choroidal nevus, peripheral exudative hemorrhagic chorioretinopathy, congenital hypertrophy of the retinal pigment epithelium (RPE), hemorrhagic RPE detachment, choroidal hemangioma, age-related macular degeneration, RPE hyperplasia, and others. These pseudomelanomas can be differentiated from choroidal melanoma by their unique clinical features.Choroidal melanoma is a serious malignancy with characteristic features. Early detection and therapy is important. Pseudomelanomas can lead to diagnostic confusion; however, clinical features aid in differentiation.

Summary Aims To document the histopathological features of selftreatment of cutaneous lesions with the escharotic agent black salve. Methods Retrospective review of cutaneous lesions treated with black salve retrieved from the files of four pathology practices in Western Australia and review of the published literature. Results 16 lesions from 11 patients who self administered black salve for the treatment of skin lesions were reviewed. Clinical diagnoses at the time of biopsy included scar, keloid scar, pseudomelanoma, basal cell carcinoma, squamous cell carcinoma and cutaneous necrosis. Histopathological features identified in our series included scarring, granulomatous inflammation, implanted foreign material, reactive stromal atypia and suppurative necrosis. Residual neoplasia was present in two of 16 cases, including a basal cell carcinoma and a melanocytic naevus. An additional 13 lesions in 10 patients were identified in the medical literature, including cases with poor cosmetic outcomes and cases of malignant tumours masked by uncontrolled escharotic treatment. Conclusions Availability of black salve through easily accessible internet sites appears to be associated with persisting use of this agent for the self-management of cutaneous lesions. Awareness of the potential complications and range of histopathological features associated with self-administration of escharotic agents is of importance to dermatologists and histopathologists.

Dear Editor, Nevi are senescent and benign tumors of melanocytes, some of which can progress to melanoma (Gray-Schopfer et al., 2007). BRAFV600E is the most frequent mutation in human nevi and melanoma, and promotes senescence in human melanocytes (Gray-Schopfer et al., 2007). The functional activity of BRAFV600E has been validated in both zebrafish and mouse animal models (Damsky and Bosenberg, 2010; Patton et al., 2010). Both models display nevus-like melanocytic hyperplasia; however, the focus has been on the malignant transformation of these nevi to melanoma and not the nevi themselves. In zebrafish, the transgenic expression of BRAFV600E from the mitfa promoter can promote fish-nevus development, but an additional genetic mutation, for example, in p53 is required to promote progression to malignancy (Patton et al., 2005). BRAFV600E nevi develop in the young adult fish, and once formed remain static, and do not continue to grow for the remainder of the life of the fish. Thus, like in humans, fish-nevi appear to have limited growth potential, most likely due to oncogenic BRAF-induced senescence pathways. Even in BRAFV600E animals that are deficient for p53, only some fish-nevi progress to melanoma (Patton et al., 2005), suggesting that the constraints on fish-nevus growth are robust and that multiple cellular changes are required to promote transformation to melanoma. We were able to exploit the regenerative capacity of the zebrafish to explore the self-renewal potential of the fish-nevus. The zebrafish pigmentation pattern consists of three pigment cell types: the melanocytes, the iridophores, and the xanthophores (Kelsh et al., 2009). Partial amputation of the fin tissue has previously been studied to dissect the genetic pathways responsible for melanocyte regeneration (Rawls and Johnson, 2000, 2001). Following microinjection of the BRAFV600E transgene into the single-cell embryo (mosaic transgenics), nevi occur randomly, with a proportion in the caudal fin (Appendix S1). Zebrafish fin pigmentation patterns are highly stereotyped, and zebrafish-nevi are clearly distinguishable from normal patterning by ectopic dark, diffusely pigmented and often larger melanocytes. This allowed us to ask whether the constraints on fish-nevus growth are maintained in the context of the regenerating fin tissue. The distal portion of the caudal fin was amputated, removing between one-quarter and one-half of the nevus, and the regrowth of the tail and fish-nevus was recorded. We reasoned that there could be four possible outcomes: nevus regrowth with the regenerating tail fin, enhanced nevus regrowth with the regenerating tail fin, no nevus growth with the regenerating tail fin, or regression of the remaining nevus. Thirty-four zebrafish displaying fish-nevi within the caudal fin underwent partial amputation (Figure 1B and Table 1). Zebrafish were imaged initially as a reference image, immediately following partial nevus removal (Figure 1A, B) and subsequently at 1-week intervals for at least 3 weeks post-surgery (Figure 1C–G). Four different outcomes were observed (Table 1). The most frequent outcome was complete regrowth of the nevus (regenerate; n = 32; Figure 1C–G). Regenerating fin nevus tissue carried the mitfa-BRAFV600E transgene cells, as confirmed by genotyping of the regenerate fin tissue (data not shown). However, because the fish are mosaic transgenics, non-nevus tail fin tissue also carried and expressed the transgene preventing us from determining the origin of the repopulating fish-nevus melanocytes. Fin regeneration without regrowth of the nevus was also observed (n = 1; non-regenerate; Figure S1), as was one case of nevus regression in which the remaining segment of nevus appeared to regress leaving the original stripe pattern evident (regression; Figure S2). Rates of fish-nevus regrowth could vary, but all fish-nevi could be clearly seen to begin recurrence within 1 week. Most fish-nevi had recurred by 3 weeks, although one fish required up to 10 weeks for complete regrowth. Three fish showed enhanced regrowth along the length of the tail fin (Figure S3). Thus, we find that most fish-nevi have the potential for recurrence within the context of the regenerating tail fin tissue. Table 1 Summary of BRAFV600E zebrafish nevus response Figure 1 Regeneration of a partially amputated fish-nevus. (A) Mosaic integration of mitf-BRAFV600E promotes fish-nevus development in wild-type zebrafish. Ectopic melanocytes form a fish-nevus in the tail fin (black tissue, ventral portion of tail fin). The red ... Fish-nevi recurrence was not altered by different wild-type background (AB or TE strains). We also tested recurrence in zebrafish disrupted for cell-to-cell contact between pigment cells in the mutant line leopard (mutation in connexin 41.8; (Watanabe et al., 2006) and in zebrafish that have fin overgrowth (longfin; mutation in kcnh2l; S. Johnson, personal communication). Fish-nevus recurrence was recorded in all fish, regardless of background (Table 1). Notably, fish-nevi could recur after multiple and successive fin amputations (up to at least three times). We then addressed the cell population that generates the recurrent nevus. One possibility is that the differentiated melanocytes in the remaining fish-nevus undergo migration and/or proliferation to repopulate the regenerating fin. Previous studies have shown that regeneration of the pigment stripes following fin amputation involves unpigmented precursor cells (Lee et al., 2010; Rawls and Johnson, 2000, 2001). Ten fish with regenerative fish-nevi were selected, and recurrence was observed in the presence of N-phenylthiourea (PTU) to block de novo melanin synthesis (Figure 2). In this way, melanin is used as a lineage tracer that pigments the new melanocytes derived from division of original nevus cells or allows for the visualization of migrating nevus cells into the regenerating tail. We found that the tail fins regenerated in PTU lack pigmentation of either the regenerating stripes or nevus cells. Unpigmented cells did repopulate the tail fin; however, because upon the initiation of melanin synthesis (24 h after removal of PTU), we observed pigmented melanocytes in the tail fin and the regenerated fish-nevus. This indicates that the melanocytes responsible for repopulating the fish-nevus, at least in the initial stages, are primarily derived from an unpigmented precursor cell type and not from significant migration or proliferation of differentiated pigmented fish-nevus melanocytes. Figure 2 Regenerating fish-nevi develop from an undifferentiated precursor. (A) A zebrafish tail fin with a fish-nevus (asterisks) was partially amputated and regrown in the presence of phenylthiourea (PTU) for 11 days (B). PTU blocks new melanin synthesis (Rawls ... Tail fin regeneration did not promote melanoma in any of the recurring fish-nevi. Notably, two nevi fish had p53+/− mutations and also did not develop melanoma (up to 3 months post-caudal fin amputation) at the regenerating nevus, despite developing tumors from additional nevi elsewhere on the body (Table 1). Following this, we wondered whether tail regeneration might stimulate tumor formation in tumor prone BRAFV600Ep53 lines in which all melanocytes carry the BRAFV600E transgene. We repeated our tail regeneration assay in five stable transgenic BRAFV600E/V600Ep53−/− zebrafish and found no progression to melanoma at the tail fin (followed up to 4 weeks post-amputation; data not shown). Likewise, amputation of the tail fins in the highly tumor prone RASV12 stable lines (Santoriello et al., 2010) also did not stimulate tumorigenesis (followed up to 3 weeks post-amputation; n = 24; data not shown). Thus, in the proliferative environment of the regenerating tail fin, sufficient cellular controls are maintained to prevent tumorigenesis in BRAFV600E- and RASV12-expressing melanocytes. In conclusion, otherwise growth-restricted zebrafish fish-nevi have the potential to repopulate large portions of a nevus from an unpigmented precursor cell type, without promoting tumorigenicity. UV light exposure and BRAF mutations contribute to nevus initiation in humans but the maintenance, recurrence, and regression of nevi are not well understood. Nevi often regress in older people (Tucker et al., 2002), and a proportion of patients display nevi recurrence following removal by surgical curettage or dermabrasion (King et al., 2009). These recurrent nevi are not tumorigenic but can often resemble a dysplastic nevus or melanoma (pseudomelanoma). The source of melanocytes that repopulate a recurrent nevus is unknown, but it has been postulated that the melanocytes may be derived from nearby melanocyte stem cells or residual nevus melanocytes at the site of removal (King et al., 2009). In our model, the regenerative nevi appear to be derived from an unpigmented precursor population, at least during the first 11 days of regeneration. The potential for differing regenerative outcomes of the fish-nevi suggests that fish-nevi may actively regulate and sustain their growth. While we do not know how human nevus maintenance compares with the zebrafish-observed nevus outcomes, this model provides a novel platform to study fundamental questions about nevus maintenance, regrowth, and regression.

Recurrent nevus phenomenon and regression in melanoma may have overlapping histologic features. The clinical findings and histologic changes in 357 cases of recurrent nevus phenomenon were compared with 34 cases of melanoma with regression. Regression was defined as (1) Early: dense lymphoid infiltrates replacing nests of melanocytes, (2) Intermediate: absence/ loss of tumor with replacement by mix of lymphocytes and melanophages and early fibrosis, and (3) Late: tumor absence with extensive fibrosis and telangiectasia, melanophages and epidermal effacement. Four broad histologic patterns of recurrent nevus were identified and classified into type 1: junctional melanocytic hyperplasia with effacement of the retiform epidermis and associated dermal scar, type 2: compound melanocytic proliferation with effacement of the retiform epidermis and associated dermal scar, type 3: junctional melanocytic hyperplasia with retention of the retiform epidermis, and type 4: compound melanocytic hyperplasia with retention of the retiform epidermis and scar. Melanomas with early and intermediate regression were recognizable due to the presence of residual melanoma. Melanomas with late regression had overlapping features of type 1 and 2 recurrent nevi. Type 3 recurrent nevi resembled primary melanoma with scar/fibrosis. Histologically, the vast majority of recurrent nevi are readily identifiable; however, partial biopsies or cases without prior knowledge of the original biopsy may lead to misdiagnosis. This is especially true in recurrent nevus and regression in malignant melanoma, where these two lesions share overlapping histologic features. Correlation with the clinical findings and prior biopsy will avoid these pitfalls.

BACKGROUND: The aim of this study was to evaluate what are the most frequent ocular diseases that were suspected for choroidal melanoma (”pseudo melanoma”). PATIENTS AND METHODS: The data of all patients who were seen in the University Hospital of Mainz under the suspicion of choroidal melanoma between 1.1.1994 and 1.1.2004 and underwent ultrasound examination, fluorescein angiography or fundus photography, were analysed retrospectively. Among 458 examined eyes a choroidal melanoma was diagnosed in 212 cases. In 246 cases the diagnosis was “pseudomelanoma”. RESULTS: The most frequent ocular diseases suspected for choroidal melanoma were “suspicious nevi” in 31 % of the cases and “disciforme macula degeneration” in 34 %. Less frequently we found hyperplasy of pigment epithelium (5 %), melanocytoma (10 %), choroidal haemangioma (6 %), choroidal detachment (7 %) and retinal macroaneurysma with epi-/subretinal haemorrhages (3 %). Rare diagnoses were orbital tumour, scleritis posterior and a combined hamartoma of retina and pigment epithelium (4 % at all). In 58 eyes without a fundus view, ultrasound revealed an intraocular tumour. In these cases vitrectomy/cataract extraction was performed and we found a choroidal melanoma in 5 eyes, a disciforme macula degeneration in 48 eyes and in 5 eyes a retinal macroaneurysma. CONCLUSIONS: Age-related macula degeneration (AMD) is the cause for one third of all pseudomelanomas. Because of its increasing incidence in the future, more attention must be paid to AMD in the differential diagnosis of chorioretinal lesions suspicious of melanoma.

The re-emergence of a melanocytic proliferation at the site of a previously excised pigmented lesion may not only cause great concern clinically but may also be amongst the most difficult of all melanocytic lesions for pathologists to assess. These lesions can adopt an appearance which may be impossible to confidently distinguish from a regressing or traumatised melanoma on histological grounds alone. For this reason, careful attention must be paid to the clinical context which has given rise to the lesion or a misdiagnosis may occur. In the absence of a corroborating history of prior surgery or trauma to the site, a diagnosis of a regenerating naevus may only be provisional. When considering a diagnosis of regenerating naevus, whenever possible, it is important to review and confirm the benign nature of the precursor lesion. Nevertheless, 50 years of research into this phenomenon has identified certain characteristic clinical features and histological patterns which provide clues both to clinicians and pathologists that will assist them to make the correct diagnosis and avoid over diagnosing as melanoma what is ultimately a benign process.

Melanonychia is uncommon. We report the first case of histopathologic recurrence of a completely excised subungual congenital nevus that presented as congenital melanonychia.

Recurring nevus or pseudomelanoma is a benign melanocytic lesion that appears in the same location after an incomplete surgical removal of nevi. These pigmen...

Melanocytoma is a deeply pigmented variant of melanocytic nevus that classically occurs in the optic disk, sometimes with contiguous involvement of the adjacent retina or choroid. Historically, this tumor was often confused with malignant melanoma both clinically and histopathologically. Today, however, it is generally recognized by its typical clinical features that differ from most melanomas and erroneous enucleation is rarely done. Histopathologically, melanocytoma is composed of intensely pigmented round to oval nevus cells with benign features. Although traditionally believed to be a relatively stationary lesion, it is now known to exhibit minor enlargement in 10--15% of cases and can cause minor visual loss by a variety of mechanisms. In rare instance, it can induce severe visual loss due to spontaneous necrosis of the lesion or compressive optic neuropathy. More importantly, it can exhibit malignant transformation into melanoma in 1--2% of cases. Ophthalmologists should be familiar with melanocytoma of the optic disk and affected patients should be followed periodically.

A 3-year-old boy with recessive dystrophic epidermolysis bullosa developed a rapidly growing, large, acquired irregular melanocytic nevus on the lower aspect of the back. The lesion was clinically atypical and fulfilled the criteria for a malignant melanocytic proliferation. A complete surgical excision was performed. Histopathologic examination disclosed a compound melanocytic nevus without melanocytic atypia. Ultrastructural examination showed melanocytic cells located both at the roof and the floor of the blister. Several months later, three pigmentary lesions with a similar clinical appearance developed. Periodic clinical and dermoscopic examinations were recommended. Dermoscopic examination disclosed a globular pattern with brown globules and black dots distributed all over the lesions. The lesions also exhibited blue-greyish dots and multiple rounded white structures corresponding to milia-like cysts. No dermoscopic features suggestive of malignancy were noted. Acquired melanocytic nevi showing atypical clinical features have been reported to occur in areas of blistering in patients with epidermolysis bullosa. These nevi appear as large, asymmetrical pigmentary lesions with irregular borders. Initially, they are very dark in pigmentation, with color variegation and loss of pigment, and even becoming papillomatous over time. Histopathologic examination can show features of compound/junctional nevus as well as persistent/recurrent nevus. The concept of “epidermolysis bullosa nevus” has been proposed to define these peculiar lesions. The clinical, histopathologic and ultrastructural features of these nevi are reviewed. The usefulness of dermoscopic examination in the routine diagnosis and follow-up of these lesions are stressed.

Background: The increasing use of lasers for the removal of pigmented skin lesions has led to a growing risk of erroneously treated malignant melanocytic tumours. Patients and methods: In two patients, both of whom developed a melanoma, the lesions were initially misdiagnosed clinically as a benign naevus and treated with laser vaporisation. Results: On recurrence of the tumours, the diagnosis of melanoma was finally established by histological examination of the excised tumours in which differentiation from pseudomelanoma remained difficult. Conclusions: In such cases of initially misdiagnosed melanomas, laser removal not only complicates and delays the correct diagnosis but might also worsen the prognosis after recurrence of an incompletely removed tumour.

This report describes 22 Spitz nevi that seemed to have been clinically removed but persisted and clinically recurred at the biopsy site. These were evaluated in terms of histopathology, immunohistochemistry, and molecular pathology using comparative genomic hybridization (CGH) and fluorescent in situ hybridization. One of these 22 lesions was originally reported as an atypical melanocytic proliferation with some features of a Spitz nevus and was included in the study set at an early stage but was later recognized as melanoma after metastasis to regional lymph nodes 3 years after the local recurrence. We noted four histopathologic patterns in the recurrent lesions: 1) a predominantly intraepidermal pattern resembling "pseudomelanoma" as seen in recurrent "common" melanocytic nevi, 2) a compound, mostly nested pattern above or within a scar that was nearly identical to the originally biopsied Spitz nevus, 3) a nodular growth pattern that closely simulated invasive melanoma, and 4) a desmoplastic pattern resembling an intradermal desmoplastic Spitz nevus. Although the majority of recurrent lesions exhibited asymmetry and pagetoid spread, the dermal component usually had a low mitotic rate and retained architectural and cytologic maturation, which allowed distinction from invasive melanoma. Except for the metastasizing melanoma, the immunostaining pattern with S-100 and HMB-45 was identical to that previously reported for Spitz nevi. Ki67 revealed a very low proliferation rate in all cases, including the melanoma. CGH performed in 10 cases yielded results consistent with Spitz nevi in eight cases. The remaining two cases showed CGH profiles more typical of melanoma, and one of these was the above-referenced case of melanoma, proven by metastasis. Although ancillary molecular techniques such as CGH are of great help in distinguishing these from melanoma, until such techniques become widely available we advocate complete but conservative excision of any recurrent Spitz nevus.

Common variations seen in a nevus include neurotization and halo phenomenon. Other less common presentations are desmoplastic nevus, balloon cell nevus, halo nevus, dermal nevus with fatty infiltration, nevus with ossification, Meyerson’s (inflamed) nevus, recurrent nevus, nevus with trichostasis spinulosa, nevus with pseudovascular change, nevus with myxoid change, and combined nevus.

Choroidal osteoma is formed of cancellous bone and should be differentiated from calcium deposition (i.e., calcification). Dystrophic calcification occurs in dead or degenerated tissues in the presence of normal calcium metabolism. Metastatic calcification, in contrast, occurs in healthy tissues, secondary to hypercalcemia. This chapter describes choroidal osteoma and sclerochoroidal calcification, emphasizing the differentiating features.

Large melanocytic nevi occurring in areas of former blistering in patients with hereditary epidermolysis bullosa (EB) pose a problem to the clinician with regard to prognosis and therapy because they may show clinical and histopathologic features strikingly resembling malignant melanoma. To investigate clinical and histologic criteria as well as the biologic behavior of these nevi, pigmented lesions of 12 patients (EB simplex, n = 1; junctional EB, n = 7; dystrophic EB, n = 4) of the Austrian EB registry were analyzed. Clinically, the nevi are up to palm sized, are initially very dark, and may exhibit stippled pigmentation and irregular borders that outline areas of former blisters. Over time they usually lose pigment, the surface gets papillomatous, and finally they acquire a shagreen-like appearance. Histopathologically, the nevi frequently exhibit a compound congenital or persisting nevus/pseudomelanoma pattern. Despite this combination of features, no malignant transformation of the nevi has been seen by us even after 20 years of prospective surveillance. Because nevi with these criteria do not fit in any of the known categories, we suggest the term EB nevi.

In non-Caucasians, malignant melanoma most frequently affects the sole of the foot. To improve the prognosis in such patients, accurate diagnosis of early lesions is extremely important, and, to avoid potentially mutilating surgery, it is equally important to identify benign acral nevus. Clemente and colleagues recently proposed a new clinicopathological entity, designated acral lentiginous nevus (ALN) of the plantar skin. The clinical and histopathological characteristics of these nevi enable clinicians to distinguish them from ordinary nevi and melanoma. We report four additional cases of ALN, which can be classified as belonging to the "pseudomelanoma" group.

An 82-year-old white man was referred for a suspected inferior pigmented, choroidal melanoma in his left eye. The patient stated that his left eye had been hit by a tree branch approximately 40 years prior, and he had not been able to see with it since then. Dilated fundus examination revealed a 14 × 8 mm dark, dome-shaped choroidal mass located inferiorly. Transillumination of the eye revealed no defects. Ultrasonography revealed a hollow lesion, consistent with a senile, dark dislocated cataract. [ Ophthalmic Surg Lasers Imaging Retina. 2014;45:328–330.]

AM is a 75-year-old woman who was scheduled for cataract surgery on a 4+ nuclear sclerotic lens. The ophthalmologist had difficulty visualizing the fundus and performed a B-scan examination. When the probe was placed on the posterior temporal sclera against the orbital rim and aimed towards the cornea, a dome-shaped mass was imaged (Fig. 1). The diagnosis of a probable ciliary body melanoma was made, and the patient was referred to an oncologist to be evaluated for systemic metastases. The workup was negative for tumor, and a discussion was instituted regarding treatment options, including enucleation. This greatly concerned the patient and she sought a second opinion.

CD is a 43-year-old man with a history of a serious infection in his left eye years ago that resulted in some decreased sight in that eye. His vision had decreased slowly since that time and was very poor at the time of presentation to an optometrist. Examination found vision in that eye of counting fingers at 1 m and 20/30 in the right eye. Slit-lamp examination showed scarring of the left corneal stroma with a poor view of the anterior chamber and lens.

TD is a 52-year-old man who was seen for a routine eye exam by his optometrist and found to have a lightly pigmented fundus lesion near the nasal equator of his left eye. It was assumed to be a melanoma, and the patient was so informed. He was referred to a retinal specialist for the initiation of therapy. The retinologist agreed that it was most likely a choroidal melanoma, but before treatment was begun, a fluorescein angiogram was performed and the man was sent for echographic examination.

Because of their similar appearance to melanoma, recurrent and persistent nevi may pose diagnostic difficulties. We present three cases of recurrent nevi and their clinical, dermatoscopic and dermatopathologic findings.

Purpose To describe two patients who developed scleral thinning as a late complication of scleral tunnel incision for cataract extraction. Design Observational case report and interventional case report. Methods A 75-year-old man had an asymptomatic gray-brown subconjunctival nodule in the location of the healed scleral tunnel incision for cataract surgery. A 62-year-old man had a biopsy of a brown conjunctival nodule at the site of a scleral tunnel incision for cataract surgery. Results The 75-year-old patient with prolapsed uveal tissue was followed up for 4 years without change in the wound defect. The 62-year-old patient had a biopsy because the exposed ciliary body mimicked a melanoma. Conclusions Scleral defects with herniated uveal tissue as a late sequela of scleral tunnel incision for cataract surgery should be differentiated from melanoma and can be safely observed for years when covered by conjunctiva.

Purpose To describe a series of 20 patients with opaque media, referred with uveal melanoma, but subsequently found to have pseudomelanoma from oblique imaging of hypermature cataract on ultrasonography. Design Case series. Participants Twenty patients. Methods Retrospective chart review. Main Outcome Measures Ultrasound imaging. Results All eyes had opaque media from hypermature cataract with no view of the fundus. All were referred because of suspected uveal melanoma, based on ultrasonographic imaging. The echogenic mass appeared to be in the ciliary body (n = 17) or choroid (n = 3). The median patient age was 54 years (range, 17–86 years). Most patients were white (n = 13) or black (n = 4). There was a history of eye trauma (n = 3) and ocular surgery (n = 1). Visual acuity was light perception to hand movements (n = 18) and 20/50 to 20/100 (n = 2). The cataract was in an anatomic position (n = 18) or subluxated (n = 2). On B-scan ultrasonography, the mass was dome-shaped (n = 10) or elliptical (n = 10), displayed an acoustically hollow center with a dense rim (n = 20), and was located in the ciliary body (n = 17) or choroid (n = 3). The mean thickness was 7.2 mm and the mean base was 9.3 mm. Features suggestive of cataract rather than melanoma included a lack of contiguity with the uvea (n = 20) on videoimaging using standard ultrasonography and ultrasound biomicroscopy, a lack of a transillumination shadow, and a lack of a sentinel vessel. For those in the ciliary body region, an additional feature was the ultrasonographic presence of mass in all 4 quadrants (n = 17), representing oblique imaging of the lens equator. For those in the choroid region, the pseudomelanoma shifted when the patient was imaged in a reclined compared with an upright position. After cataract surgery, the lack of melanoma was confirmed. Conclusions Dense cataract can preclude a fundus view, necessitating ultrasonography for imaging the posterior segment of the eye. Ultrasonographic confusion with a ciliary body and choroidal melanoma can occur because the dome-shaped cataract can simulate a dome-shaped melanoma. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose: To report the diagnoses of lesions initially misdiagnosed as ocular melanoma. Methods: This retrospective study included all new patients who were referred with a presumptive diagnosis of choroidal melanoma to the ocular oncology clinic at Farabi Eye Hospital from January 2009 to December 2012. Each patient underwent a full ocular examination and B-scan ultrasonography by an ocular oncologist. The final diagnosis was made based on a combination of clinical features, fluorescein angiography, indocyanine green angiography, optical coherence tomography, neuroimaging and biopsy when necessary. Results: Out of a total of 194 patients referred with a preliminary diagnosis of choroidal melanoma, 73 (37.6%) subjects actually had pseudomelanoma. Mean age in this subgroup was 46.5±23.1 (range, 1.5-85) years. The most common entities simulating a choroidal melanoma were vasoproliferative tumors (12 cases), choroidal metastasis (11 cases), peripheral exudative hemorrhagic chorioretinopathy (10 cases), lymphoproliferative infiltrative lesions (6 cases) and melanocytoma (5 cases). Conclusion: A wide range of lesions may mimic ocular melanoma; a correct diagnosis may be made by a combination of clinical examination and imaging modalities.

An 18-year-old man had a melanocytic nevus on the chin that had been treated with three different lasers at a private clinic for 2.5 years. This lesion was excised and sent to a pathologist. The initial histological diagnosis was reported as compound nevus coexistent with changes suspicious of malignant melanoma. The reevaluation of histology together with the clinical information that the lesion had been pretreated with laser resulted in a revised diagnosis of pseudomelanoma. It is important to be aware of this benign pseudomelanoma, which can arise as a complication of laser therapy, to avoid subjecting patients to unnecessary surgical procedures or other forms of adjuvant treatment.

The RCM criteria of most types of melanocytic nevi have been extensively described in the literature within the past years [1–4]. This chapter complements this body of knowledge by describing the RCM features of less frequent types of nevi, namely blue, “black” and recurrent nevi. Common to these nevus variants is that they are often the clinical outlier or “ugly duckling” among the patient’s moles, and as such, these nevi tend to raise some clinical concern; moreover, their dermoscopic features are often equivocal. To this end, RCM can reveal additional architectural and cellular details about these nevi, and thus can serve as a helpful adjunct for diagnosis and management decision. In the following sections, we describe the RCM features of these nevi in the context of the current technical limitations of RCM, such as the restricted depth of penetration of light and the limited cellular details.

Intense pulsed light (IPL) therapy using noncoherent broad-spectrum light has been reported to be effective for hair removal, and also for treating superficial pigmented lesions like ephelides and solar lentigines. We report complete regression of a pigmented melanocytic nevus, histologically confirmed, after hair removal treatment with IPL. The use of lasers and IPL is a common procedure used by dermatologists and even other professions for the treatment of cosmetically troubling skin conditions. The main advantage of such treatment is a reduction of surgical scars, thus producing a favorable cosmetic outcome, but a major limitation is that histopathologic diagnosis is not usually obtained prior to treatment. Such devices should be carefully used in patients with potentially dangerous melanocytic lesions. We also review the recent literature regarding inadequate treatment of melanocytic lesions with lasers.

Background Melanocytic nevi may exhibit histologic features in common with cutaneous melanoma, creating diagnostic difficulties. Objective We sought to assess the clinical behavior of melanocytic nevi with pseudomelanomatous features in association with dermal fibrosis. Methods Forty-two melanocytic nevi with pronounced fibrosis and associated pseudomelanomatous changes were collected and studied clinically and histologically. Results The fibrosis was centrally located and laminated in appearance. It imparted a trizonal appearance: a junctional component with prominent single cells and/or irregular nests, underlying fibrosis, and a mature dermal component. No recurrence or metastases were evident over an average follow-up period of 2 years. Limitations The follow-up period was short. Conclusions The central location and laminated appearance of the fibrosis suggest that this may represent the extreme end of a spectrum of fibroplastic changes in "Clark/dysplastic" nevi. Adjacent features of "Clark/dysplastic" nevi and limitation of pseudomelanomatous features to the perifibrotic focus are important in accurately identifying these lesions. Although melanocytic nevi with exaggerated fibroplasia may show foci with melanoma-like features, they do not appear to exhibit aggressive clinical behavior.

Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare condition characterized by either subretinal exudates or subretinal hemorrhage outside the macula. The objective of this case report is to describe PEHCR lesions in Korean patients.Five eyes of four patients are reviewed.All cases were characterized by either peripheral subretinal exudates or hemorrhage with age-related degeneration. Four of the lesions appeared as subretinal masses, and the other manifested as a large retinal pigment epithelial alteration combined with subretinal exudates and subretinal fibrosis. Two of the patients evidenced serious visual impairment induced by massive subretinal hemorrhage extending to the fovea. Visual acuity in the other three eyes studied remained stable.PEHCR appears to be a variant of age-related macular degeneration that occurs in Asians. Although PEHCR is known to be self-limiting, it frequently causes subfoveal extensions of subretinal blood and fluid.