Differential diagnosis between spitz nevi and melanomas by means of in-vivo confocal microscopy

Spitz nevi may be often confused with malignant melanoma, because of its rapid growth and alarming clinical features. In vivo confocal reflectance microscopy (CRM) is a novel technique enabling the noninvasive imaging of the skin at a cellular level resolution. Twelve Spitz and 25 melanomas (MMs) were studied by means of CRM (Vivascope 1000, Lucid Inc., USA) and digital dermoscopy (Videocap 200, DS-Mediroup, Italy) for in vivo characterization of cytological and architectural features at CRM, and correlation with dermoscopy and histology. Although large cells with bright cytoplasm and dark eccentric nucleus, sometimes spreading upwards in a pagetoid fashion, were observed both in Spitz nevi and MMs, in the latter case they were more numerous and irregularly shaped. Dermoscopic globules corresponded to cell clusters at CRM and melanocytic nests at histopathology. Spitz nevi frequently presented a peripheral rim of medium sized peripheral clusters, constituted by compact aggregates of large polygonal cells, sometimes observable also on the whole lesion area. In MMs cell clusters were frequently constituted by sparse cells intercalated with thin fibrils giving a multi-lobate appearance or by large confluent aggregates of low reflecting polygonal or elongated cells, resulting in a cerebriform appearance. Although CRM appeared useful for distinction between melanocytic lesions, Spitz nevi presenting numerous atypical cells and dermal-epidermal architecture disarrangement can not be always distinguished from MMs, owing to the limited penetration of the near-infrared laser light, not enabling the evaluation of ‘cell maturation’ with increasing depth.