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Resumen El miedo a realizar intervenciones en la una por el riesgo de distrofia residual, la dificultad de procesado y de interpretacion de las biopsias ungueales, asi como la falta global de experiencia en este campo han hecho que las melanoniquias ungueales en general (y las lesiones melanociticas subungueales en particular) sean un tema poco atractivo tanto para dermatologos como para patologos. A pesar de la indudable complejidad de este campo, el manejo de las tecnicas de biopsia ungueal, el correcto procesado y orientacion de las muestras y el conocimiento de las particularidades histologicas del aparato ungueal pueden facilitar mucho esta labor. La biopsia longitudinal escisional ofrece la interpretacion histologica mas sencilla y tiene bajo riesgo de generar distrofia ungueal, si se realiza correctamente. Los datos clinicos y epidemiologicos son fundamentales: el diagnostico de melanoma subungueal en la infancia es excepcional, e incluso lesiones con caracteristicas clinicas y/o histologicas atipicas constituyen, con toda probabilidad, lesiones benignas. La presencia de melanocitos suprabasales y otros hallazgos que serian sospechosos de malignidad en lesiones en otras localizaciones se consideran normales en el aparato ungueal. El melanoma subungueal tiene un patron lentiginoso en estadios precoces y parece que la presencia de un infiltrado inflamatorio, acompanando a lesiones subungueales lentiginosas atipicas, es uno de los primeros hallazgos diagnosticos de esta lesion.

Background We reviewed all cases of multiple primary melanoma diagnosed at our department over a 32-year period (1987–2019) to better characterize this subgroup of patients and develop a tailored protocol to offer them closer follow-up. Methods Retrospective, observational, descriptive study of patients diagnosed with multiple primary melanoma at a tertiary care hospital between January 1987 and March 2019. We collected clinical, epidemiologic, and histologic characteristics of primary and subsequent melanomas and performed a descriptive analysis. Results Thirty-one patients (15 men and 16 women) with a median age of 67 years (range, 36–85 years) were included. Second primary melanomas were diagnosed after a median of 2 years (range, 0–4 years). The median number of melanomas per patient was 2 (range, 2–6). Of the 31 patients, 25 had 2 primary melanomas (80%), 4 had 3 melanomas (13%), and 2 patients each had 5 and 6 primary melanomas. Subsequent melanomas were less invasive than the initial primary melanomas. Median Breslow thickness was 1 mm (range, 0.67–4 mm) for the first primary melanoma and 0.5 mm (range, 0.32–2.42 mm) for subsequent melanomas. Conclusions Subsequent melanomas are thinner than primary melanomas. We observed an increase in the number of cases of multiple primary melanoma diagnosed in the last 2 years of our study. Our findings highlight the importance of close, long-term follow-up of patients.

Resumen: Introducción: Realizamos una revisión de los melanomas múltiples primarios que se han diagnosticado en nuestro servicio a lo largo de los últimos 32 años (1987-2019) con el objetivo de tener mejor caracterizada nuestra población de pacientes con melanoma y poder ofrecerles un seguimiento más estrecho mediante la elaboración de un protocolo de seguimiento personalizado. Metodología: Estudio observacional, descriptivo y retrospectivo de los melanomas primarios múltiples diagnosticados en un hospital de tercer nivel entre enero de 1987 y marzo de 2019. Se recogieron las características clínicas, epidemiológicas e histológicas de los melanomas primarios, así como de los subsecuentes melanomas, y se realizó un análisis descriptivo de las mismas. Resultados: Se incluyeron 31 pacientes (15 hombres y 16 mujeres), con una media de edad de 67 años (intervalo: 36-85 años). La mediana de tiempo transcurrido desde el diagnóstico del primer melanoma primario y el del segundo melanoma fue de 2 años (intervalo 0-4 años). La mediana del número de melanomas por paciente fue de 2 (entre 2 y 6). Del total de 31 pacientes, 25 padecieron 2 melanomas (80%), 4 de ellos 3 melanomas (13%), y 2 pacientes presentaron 5 y 6 melanomas primarios, respectivamente. Los segundos melanomas primarios o subsecuentes eran menos invasivos comparados con los primeros. La mediana de índices de Breslow fue de 1 mm en los primeros (entre 0,67 y 4 mm) y de 0,5 mm (0,32-2,42 mm) en los segundos. Conclusiones: Los melanomas subsecuentes son más finos que los primeros melanomas diagnosticados. Se encontró un aumento de la frecuencia en los dos últimos años de melanomas múltiples primarios. Estos datos resaltan la importancia del seguimiento estrecho y a largo plazo de estos pacientes. Abstract: Background: We reviewed all cases of multiple primary melanoma diagnosed at our department over a 32-year period (1987-2019) to better characterize this subgroup of patients and develop a tailored protocol to offer them closer follow-up. Methods: Retrospective, observational, descriptive study of patients diagnosed with multiple primary melanoma at a tertiary care hospital between January 1987 and March 2019. We collected clinical, epidemiologic, and histologic characteristics of primary and subsequent melanomas and performed a descriptive analysis. Results: Thirty-one patients (15 men and 16 women) with a median age of 67 years (range, 36-85 years) were included. Second primary melanomas were diagnosed after a median of 2 years (range, 0-4 years). The median number of melanomas per patient was 2 (range, 2-6). Twenty-three of the 31 patients, 25 had 2 primary melanomas (80%), 4 had 3 melanomas (13%), and 2 patients each had 5 and 6 primary melanomas. Subsequent melanomas were less invasive than the initial primary melanomas. Median Breslow thickness was 1 mm (range, 0.67-4 mm) for the first primary melanoma and 0.5 mm (range, 0.32-2.42 mm) for subsequent melanomas. Conclusions: Subsequent melanomas are thinner than primary melanomas. We observed an increase in the number of cases of multiple primary melanoma diagnosed in the last 2 years of our study. Our findings highlight the importance of close, long-term follow-up of patients.

The study of subungual melanocytic lesions can present challenges because of the clinical and histologic characteristics of the nail unit and the difficulty of performing nail biopsies and processing specimens. These lesions can be even more challenging in children due to differences in clinical and epidemiological profiles between the adult and pediatric populations. Many of the clinical features of subungual melanocytic lesions that would raise alarm in an adult do not have the same implications in children. Consensus is also lacking on when a nail biopsy is needed to rule out malignancy in the pediatric setting. In view of these considerations and the rarity of subungual melanoma in childhood, the recommended approach in most cases is a watch-and-wait strategy. Subungual melanocytic lesions in children may also show atypical histopathologic features that are not necessarily associated with aggressive behavior. Subungual melanoma is very rare in childhood, with just 21 cases described to date. None of the patients developed visceral metastasis or died as a result and the diagnosis was controversial in many of the cases. Considering the above and the significantly higher frequency and particular characteristics of longitudinal melanonychia with a benign etiology in children, subungual melanocytic lesions should be managed differently in this setting than in adults. In most cases, a watch-and-wait approach is the most appropriate strategy.

Both dermatologists and pathologists sometimes find daunting the evaluation of melanonychia (especially subungual melanocytic lesions) because of the fear of performing nail surgery due to the risk of dystrophy, difficulties processing and interpreting nail biopsy specimens, and a general lack of experience in the field. Nevertheless, mastery of nail biopsy techniques, correct processing and orientation of specimens, and familiarity with the histologic particularities of the nail apparatus can attenuate the undoubted complexity and facilitate the tasks involved. Longitudinal excision is the biopsy technique that ensures the simplest histologic interpretation, and it is associated with a low risk of nail dystrophy when performed correctly. Clinical and epidemiological data are crucial. Subungual melanoma in childhood, for instance, is very rare and even lesions with atypical clinical and/or histologic features are probably benign. The presence of suprabasal melanocytes and other findings that would suggest malignancy at other sites are considered normal in the nail apparatus. Subungual melanoma shows a lentiginous pattern in the early stages of disease, and detection of an inflammatory infiltrate accompanying atypical lentiginous subungual lesions would appear to be one of the first diagnostic findings.

Resumen Introduccion y objetivos El pilomatricoma es la segunda neoformacion cutanea mas frecuente en la infancia y la juventud, con un amplio diagnostico diferencial. El objetivo principal del estudio fue determinar la incidencia de pilomatricomas en nuestro hospital y sus caracteristicas en relacion con: edad, sexo, localizacion, sintomas, traumatismo previo, diagnostico clinico, enfermedades asociadas, casos multiples, caracteristicas ecograficas, tratamiento quirurgico y tecnica anestesica y complicaciones posteriores. Material y metodo Se recogieron de forma retrospectiva los pilomatricomas extirpados quirurgicamente en nuestro hospital de enero de 2004 a diciembre de 2012 a partir de la base de datos de anatomia patologica. Resultados Se estudiaron 261 pilomatricomas en 239 pacientes, 120 eran mujeres y 119 varones de edades comprendidas entre 1 y 83 anos, con una media de 26,4 anos. La forma de presentacion mas frecuente fue como un nodulo firme, subcutaneo, asintomatico en el 82% de los casos. La localizacion mas frecuente fue la cabeza y el cuello (49,81%). El diagnostico clinico preoperatorio fue acertado en el 54,4%. Cincuenta y nueve pacientes tenian otras enfermedades y 7 recordaban traumatismo previo en la zona. Se registraron 17 casos multiples, uno familiar, y 2 en pacientes con enfermedad de Steinert. En 57 lesiones se realizo ecografia de partes blandas, con imagenes compatibles con pilomatricoma en 48. Ciento ochenta y cinco pilomatricomas se extirparon con anestesia local y 76 con anestesia local y general. Como complicaciones posquirurgicas hubo un caso de cicatriz hipertrofica y otro de dehiscencia. Conclusiones El nuestro es el estudio retrospectivo que recoge el mayor numero de casos en nuestro pais y uno de los que comunica mayor incidencia de casos. Ademas, se estudian variables no recogidas en otras series.

Pilomatricoma is the second most common skin tumor in childhood and youth and it has a broad differential diagnosis. The main objective of the present study was to determine the incidence of pilomatricomas in our hospital and to analyze the following variables: patient age and sex, tumor site, symptoms, previous trauma, clinical diagnosis, associated diseases, number of cases of multiple tumors, ultrasound findings, anesthetic and surgical techniques, and postoperative complications.This was a retrospective study of the pilomatricomas surgically excised between January 2004 and December 2012 and registered in the database of the pathology department of our hospital.We found 261 pilomatricomas in 239 patients (120 female and 119 male) between 1 and 83 years of age (mean age, 26.4 years). The most common presentation was as a firm subcutaneous nodule, which was asymptomatic in 82% of cases. Tumors most commonly affected the head and neck (49.81%). Preoperative diagnosis was correct in 54.4% of cases, concomitant diseases were present in 59 cases, and 7 patients reported a history of trauma in the area of the tumor. There were 17 cases of multiple tumors, 1 case in a patient with familial disease and 2 in patients with Steinert disease. Soft-tissue ultrasound was performed on 57 lesions; images were compatible with pilomatricoma in 48 cases. Tumor excision was performed under local anesthesia in 185 cases and under local and general anesthesia in 76. The postoperative complications were hypertrophic scarring and wound dehiscence (1 case each).This was a retrospective study with the largest series recorded in Spain and with one of the highest incidences. In addition, we report on variables not described in other studies.

Se presenta el caso de un varon de 49 anos, fumador acti-vo, pintor de profesion y sin enfermedad pulmonar conocida, que fue estudiado en nuestra consulta ante el hallazgo de un patron intersticial en una radiografia de torax. En la tomo-grafia computarizada toracica que se le realizo, se evidencio un patron bilateral difuso en vidrio deslustrado. La biopsia pulmonar fue la prueba que permitio establecer el diagnosti-co definitivo. En ella se apreciaron cumulos de lipidos intra-alveolares, en forma de globulos de tamano variable, rodeados de numerosos macrofagos, focalmente multinuclea-dos, hallazgos compatibles con una neumonia lipoidea exoge-na. Dada la profesion del paciente, se le recomendo evitar la exposicion laboral a parafinas y a pulverizaciones oleosas. Tras la retirada de dicha exposicion, se observo una evolu-cion favorable, con mejoria clinica y funcional del paciente

A 49-year-old man with no known history of pulmonary disease was treated at our hospital after observation of an interstitial pattern on a chest film. The patient was a smoker and professional painter. Computed tomography of the chest showed a diffuse bilateral ground-glass pattern. The lung biopsy showed intra-alveolar lipid accumulation in the form of vacuoles of varying sizes surrounded by numerous focally multinucleated macrophages, establishing a definitive diagnosis of exogenous lipoid pneumonia. Given the patient's profession, he was recommended to avoid workplace exposure to paraffins and oily sprays. The clinical course was favorable after exposure was stopped, with improved lung function and symptoms.