Baseline factors influencing decisions on digital follow-up of melanocytic lesions in daily practice: An Italian multicenter survey

Recognition of early melanoma: a monocentric dermoscopy follow-up study comparing de novo melanoma with nevus-associated melanoma

BACKGROUND

The earlier detection of melanomas occurring within preexisting nevi is theoretically possible using sequential dermoscopy. Characterizing the early follow-up changes of nevus-associated melanomas (NAMs) and differentiating them from those observed in de novo melanomas (DNMs) may help the earlier recognition of NAMs.

METHODS

Using descriptive dermoscopic features to detect focal changes, we blindly evaluated retrospectively the baseline and follow-up images of 32 melanomas that were subsequently classified as histopathologically defined NAMs or DNMs.

RESULTS

Correlates of growth, as structureless brown‐black areas or clods, complemented each other for the identification of DNMs at baseline (structureless brown‐black areas: 66.7% DNMs, 15% NAMs, P < 0.01; combined with clods, one or the other being present: 100% DNMs, 30% NAMs, P < 0.01) and when considering their baseline presence or their appearance at follow‐up (100% DNMs, 35% NAMs, P < 0.01). Correlates of fibrosis, as white lines, when considering their baseline presence or their appearance at follow-up, were associated with NAMs (60%, 16.7% DNMs, P = 0.027).

CONCLUSION

Significant differences, distinguishing NAMs from DNMs, were detected particularly when considering both baseline signs and follow-up changes. Earlier identification of NAMs and their subsequent improved histological characterization will help define the subgroup of high-risk patients, for whom comprehensive image monitoring may be beneficial.

Reflectance confocal microscopy as a second-level examination in skin oncology improves diagnostic accuracy and saves unnecessary excisions: a longitudinal prospective study

BACKGROUND

Dermatoscopy increases both the sensitivity and specificity of melanoma diagnosis. Reflectance confocal microscopy (RCM) is a noninvasive technique that complements dermatoscopy in the evaluation of equivocal lesions at cellular resolution.

OBJECTIVES

To determine prospectively the potential impact of confocal microscopy when implemented in a routine melanoma diagnosis workflow.

METHODS

Patients referred to a single melanoma clinic were consecutively enrolled. At dermatoscopy, patients were referred to one of the following pathways: (i) no further examination or (ii) RCM examination. On examination atypical lesion(s) were referred for either (a) RCM documentation (lesions with consistent suspicious clinical/dermatoscopic criteria, already qualified and scheduled for surgical excision) or (b) RCM consultation for equivocal lesions, where RCM diagnosis would determine lesion definite outcome (excision or digital follow-up).

RESULTS

Reflectance confocal microscopy examination was performed for 41% of 1005 patients enrolled. In two-thirds of these cases RCM influenced the lesion outcome. The systematic application of RCM for equivocal lesions saved over 50% of benign lesions from unnecessary excision. The number needed to excise a melanoma was 6·8 with RCM examination, compared with a hypothetical 14·6 without RCM evaluation.

CONCLUSIONS

Reflectance confocal microscopy as a second-level examination to dermatoscopy proved to be highly accurate in diagnosis and reduced the number of unnecessary excisions. Improved accuracy, considering that RCM enabled the detection of the six melanomas (2%) in the group of 308 lesions eligible for follow-up, also minimizes the risk of referring a melanoma to digital dermatoscopy monitoring, and potentially losing the patient to follow-up.

Selective use of sequential digital dermoscopy imaging allows a cost reduction in the melanoma detection process: a belgian study of patients with a single or a small number of atypical nevi

Background

Dermoscopy is a technique which improves melanoma detection. Optical dermoscopy uses a handheld optical device to observe the skin lesions without recording the images. Sequential digital dermoscopy imaging (SDDI) allows storage of the pictures and their comparison over time. Few studies have compared optical dermoscopy and SDDI from an economic perspective.

Objective

The present observational study focused on patients with one-to-three atypical melanocytic lesions, i.e. lesions considered as suspicious by optical dermoscopy. It aimed to calculate the “extra-costs” related to the process of melanoma detection. These extra-costs were defined as the costs of excision and pathology of benign lesions and/or the costs of follow-up by SDDI. The objective was to compare these extra-costs when using optical dermoscopy exclusively versus optical dermoscopy with selective use of SDDI.

Methods

In a first group of patients, dermatologists were adequately trained in optical dermoscopy but worked without access to SDDI. They excised all suspicious lesions to rule out melanoma. In a second group, the dermatologists were trained in optical and digital dermoscopy. They had the opportunity of choosing between immediate excision or follow-up by SDDI (with delayed excision if significant change was observed). The comparison of extra-costs in both groups was made possible by a decision tree model and by the division of the extra-costs by the number of melanomas diagnosed in each group. Belgian official tariffs and charges were used.

Results

The extra-costs in the first and in the second group were respectively €1,613 and €1,052 per melanoma excised. The difference was statistically significant.

Conclusions

Using the Belgian official tariffs and charges, we demonstrated that the selective use of SDDI for patients with one-to-three atypical melanocytic lesions resulted in a significant cost reduction.

Impact of mole mapping in the Italian health system

OBJECTIVE

To analyze routine clinical management of atypical melanocytic lesions through monitoring or surgery in Italian hospitals.

METHODS

A nationwide survey of clinical practices was conducted.

RESULTS

Digital monitoring is performed in most Italian hospitals and is preferred over excision for single atypical melanocytic lesions in 82% of hospitals. For multiple atypical lesions, 60% of high-volume hospitals prefer digital monitoring to surgical excision (40%). There is a statistically significant difference between high- and low-volume hospitals (60 vs. 39%; p = 0.003). Digital monitoring is performed at mean intervals of 4/5 months for both types of lesions.

CONCLUSIONS

We show an asymmetric relation between application of the method and practical impact based on available clinical evidence. Although digital monitoring provides better characterization of the evolution of melanocytic lesions, our results indicate that the advantages and limitations of this method require further investigation.

Meta-analysis of digital dermoscopy follow-up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society

It has been demonstrated that dermoscopic monitoring of melanocytic lesions allows for the recognition of melanoma in early stages while minimizing the excision of benign lesions. However, it is still pending to determine the real impact of digital follow-up in the clinical management of pigmented lesions. To assess the evidence of follow-up of melanocytic skin lesions with digital dermoscopy in the management of individuals at risk for melanoma by performing a meta-analysis. Medline database was screened, no limits in terms of date or language were applied. Original studies were selected when the following criteria were met: performed in clinical setting with clinical and dermoscopic evaluation made by physicians, data regarding population characteristics included, follow-up strategy used described. Fourteen of 145 retrieved references were retained. Included studies account for a total of 5787 patients (mean 445 per study) and 52,739 lesions monitored (mean per study 4057; range 272-11,396) with a mean of 12 lesions monitored per patient; a total of 4388 lesions (8.3%) were excised. The mean length of follow-up was 30 months. A mean of <1 lesion was excised per patient along the surveillance period. The number needed to monitor (NNM) ranged from 31 to 1008 (mean: 348) among eligible studies. For every additional month of monitoring, 1additional melanoma was detected. Using digital dermoscopy follow-up, the proportion of in situ melanoma and thin melanomas are higher than expected in general population. Chances to detect a melanoma during surveillance increase as the length of follow-up extends.

Grey-blue regression in melanoma in situ-evaluation on 111 cases

As fibrosis and melanosis are often seen in malignant melanoma, the presence of dermoscopic signs of regression may represent a clue for the diagnosis of malignancy. Our aim was to assess the frequency and extent of 11 dermoscopic features of regression evaluating dermoscopic images of 111 melanomas in situ (MIS). Regression structures (grey-blue areas, white areas, peppering, and/or blue-whitish veil) were present in 80.1% of the lesions. Approximately 80% of the lesions showed regression of dermoscopic structures and light brown areas. Most lesions showed the presence of grey-blue areas (74.7%), whereas peppering was observable in 30.6% of MIS. Areas of fibrosis were mainly observable as structureless areas with a pinkish hue (50.4%). Based on our data, the reticular pattern of blue regression and light brown areas can be considered a significant discriminator and a reliable predictor of MIS.

Reticular grey-blue areas of regression as a dermoscopic marker of melanoma in situ

BACKGROUND

By dermoscopy, regression structures are substantially defined by the presence of white and blue areas in the lesion image. As fibrosis and melanosis are often seen in malignant melanoma (MM), the presence of dermoscopic signs of regression may represent a clue for the diagnosis of malignancy.

OBJECTIVES

To assess the frequency and extent of dermoscopic signs of regression in melanoma in situ (MIS) and to describe its dermoscopic features.

METHODS

Dermoscopic images of 85 MIS, 85 invasive MMs and 85 dermoscopically equivocal lesions with a histological diagnosis of naevus were evaluated by three dermatologists, who assessed the presence of 11 parameters of regression.

RESULTS

The number of regression parameters per lesion increased according to melanoma thickness. White areas, the grey-blue veil and widespread blue areas were more frequent in invasive MMs than in the other two lesion groups, whereas light brown areas and regression of dermoscopic structures were more frequent in MIS. Peppering was observable in the same percentage of MIS and invasive MMs. Blue areas were more frequently structureless in equivocal lesions and invasive MMs, whereas the reticular pattern prevailed in MIS.

CONCLUSIONS

Frequency, morphology, extent and distribution of regression vary according to melanoma thickness and diameter. Lesions with reticular blue regression and light brown areas should undergo surgical excision for the suspicion of MIS. Moreover, the identification of the reticular pattern of blue regression can be considered a significant discriminator and a reliable predictor of MIS.

Digital image analysis for diagnosis of skin tumors

Between 1987 and 2007, different groups developed digital image analysis systems for the diagnosis of benign and malignant skin tumors. As the result of significant differences in the technical devices, the number, the nature and benign/malignant ratio of included skin tumors, different variables and statistical methods any comparison of these different systems and their results is difficult. For the use and comparison of the diagnostic performance of different digital image analysis systems in the future, some principle basic conditions are required: All used systems should have a standardized recording system and calibration. First, melanocytic and nonmelanocytic lesions should be included for the development of the diagnostic algorithms. Critical analyses of the results should answer the question if in future only melanocytic lesions should be analyzed or all pigmented and nonpigmented lesions. This will also lead to the answer if only dermatologists or all specialities of medical doctors will use such a system. All artifacts (eg, hairs, air bubbles) should be removed. The number of variables should be chosen according to the number of included melanomas. A high number of benign skin lesions should be included. Of all lesions only 10% or better less should be invasive melanomas. Each system should be developed by a training-set and controlled by an independent test-set. Each system should be controlled by the user with the final decision and responsibility and tested by independent users without any conflict of financial interest.

The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic

BACKGROUND

Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes.

OBJECTIVE

We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi.

METHODS

A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts.

RESULTS

The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (-0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (-1.209, P < .0001), increasing provider experience (-0.047, P = .029), and increased number of biopsies before the initial PLC (-0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC.

LIMITATIONS

This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period.

CONCLUSION

Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.