Does palpability of primary cutaneous melanoma predict dermal invasion?

Current controversies in early-stage melanoma: Questions on management and surveillance

There are a number of controversies and uncertainties relating to the management and surveillance of patients with early-stage, localized (ie, stage 0, I, and II) cutaneous melanoma. While tumor stage is a critical predictor of clinical outcome and guides treatment, accurate determination of stage may be affected by the biopsy technique used and the method of sectioning before histologic review. A new molecular prognostic test is available but has not been formally incorporated into staging or treatment guidelines. There are no randomized controlled clinical trials to support guidelines for surveillance following the treatment of early-stage melanoma. In the second article in this continuing medical education series, we review the controversies and uncertainties relating to these issues. The questions we address are controversial because they speak to clinical scenarios for which there are no evidence-based guidelines or randomized clinical trials with the consequence of considerable variability in clinical practice. Our goal is to provide the clinician with up-to-date contextual knowledge to appreciate the multiple sides of each controversy and to suggest pathways to resolution.

In Vivo Evaluation of Melanoma Thickness by Multispectral Imaging and An Artificial Neural Network. A Retrospective Study on 250 Cases of Cutaneous Melanoma

Aims and Background

Noninvasive diagnostic methods such as dermoscopy, sonography, palpation or combined approaches have been developed in an attempt to preoperatively estimate melanoma thickness. However, the clinical presentation is often complex and the evaluation subjective. Multispectral image analysis of melanomas allows selection of features related to the content and distribution of absorbers, mainly melanin and hemoglobin, present within the lesion. Hence, it is reasonable to assume that the same features might be useful to predict melanoma thickness.

Methods

A multispectral image system was used to analyze in vivo 1939 pigmented skin lesions. The lesion selection was based on clinical and/or dermoscopic features that supported a suspicion for melanoma. All the lesions were then subjected to surgery for the histopathological diagnosis, and 250 were melanomas. From the multispectral images of the melanomas, we selected 12 features, seven of which were used to train and test an artificial neural network on 155 and 95 melanomas, respectively.

Results

Sensitivity (i.e., melanoma ≥0.75 mm thick correctly classified) and specificity (i.e., melanoma <0.75 mm thick correctly classified) evaluated from the receiving operating characteristic curves ranged from 76 to 90% and from 91 to 74%, respectively.

Conclusions

Our approach provides results similar to those obtained with other methods and has the advantage that it is not related to the expertise of the clinician. In addition, the physical interpretation of the selected features suggests a possible role of spectrophotometry as an objective method to study the natural history of the early phases of the disease.

Dermoscopy structures as predictors of sentinel lymph node positivity in cutaneous melanoma

BACKGROUND

Histological features such as Breslow thickness, ulceration and mitosis are the main criteria to guide sentinel lymph node biopsy (SLNB) in melanoma. Dermoscopy may add complementary information to these criteria.

OBJECTIVES

To evaluate the correlation between dermoscopy structures and SLNB positivity.

METHODS

Retrospective analysis of 123 consecutive melanomas with Breslow thickness > 0·75 mm, SLNB performed during follow-up and dermoscopic images.

RESULTS

Men were more likely to have a positive SLNB. The presence of ulceration and blotch and the absence of a pigmented network in dermoscopy correlated with positive SLNB. Histological ulceration also correlated with positive SLNB. A dermoscopy SCORE predicted SLN status with a sensitivity of 96·3% and a specificity of 30·2%. When sex and Breslow thickness were added (SCOREBRESEX), the sensitivity remained at 96·3% but the specificity increased to 52·1%. This study is limited by the number of patients and was performed in only one institution.

CONCLUSIONS

Dermoscopy allowed a more precise prediction of SLN status. If a combined SCOREBRESEX was used to select patients for SLNB, 41·5% of procedures might be avoided.

Distance to diagnosing provider as a measure of access for patients with melanoma

OBJECTIVE

To examine the effect of travel distance and other sociodemographic factors on access to a diagnosing provider for patients with melanoma.

DESIGN

Analysis was performed of all incident cases of melanoma in 2000 from 42 North Carolina counties.

SETTING

Academic research.

PARTICIPANTS

Patients and providers from 42 North Carolina counties were geocoded to street address.

MAIN OUTCOME MEASURES

Associations between Breslow thickness and clinical and sociodemographic factors (age, sex, poverty rate, rurality, provider supply, and distance to diagnosing provider) were examined.

RESULTS

Of 643 eligible cases, 4.4% were excluded because of missing data. The median Breslow thickness was 0.6 mm (range, 0.1-20.0 mm). The median distance to diagnosing provider was 8 miles (range, 0-386 miles). For each 1-mile increase in distance, Breslow thickness increased by 0.6% (P =.003). For each 1% increase in poverty rate, Breslow thickness increased by 1% (P =.04). Breslow thickness was 19% greater for patients aged 51 to 80 years than for those aged 0 to 50 years (P =.02) and was 109% greater for patients older than 80 years than for those aged 0 to 50 years (P < .001). Sex, rurality, and supply of dermatologists were not associated with Breslow thickness.

CONCLUSIONS

For patients with melanoma, distance to the diagnosing provider is a meaningful measure of access that captures different information than community-level measures of rurality, provider supply, and socioeconomic status. Future work should be targeted at identifying factors that may affect distance to diagnosing provider and serve as barriers to melanoma care.

Microstaging accuracy after subtotal incisional biopsy of cutaneous melanoma

BACKGROUND

A significant portion of cutaneous melanoma may remain after subtotal incisional biopsy. The accuracy of microstaging and impact on clinical practice in this scenario are unknown.

OBJECTIVE

Our purpose was to examine microstaging accuracy of an initial incisional biopsy with a significant portion of the clinical lesion remaining (> or =50%).

METHODS

Patients with cutaneous melanoma, diagnosed by incisional biopsy with > or =50% of the lesion remaining, were prospectively evaluated for microstaging accuracy, comparing initial Breslow depth (BD1) to final depth (BD2) after excision of the residual lesion. Impact on prognosis and treatment was also evaluated.

RESULTS

Two hundred fifty of 1783 patients (14%) presented with > or =50% residual clinical lesion after incisional biopsy. The mean BD1 was 0.66 mm; the mean BD2, 1.07 mm (P = .001). After complete excision of the residual lesion, upstaging occurred in 21% and 10% became candidates for sentinel node biopsy.

CONCLUSION

An incisional biopsy with > or =50% clinical lesion remaining afterward may be inadequate for accurate microstaging of melanoma. This scenario is relatively uncommon but clinically significant.

Evaluating invasive cutaneous melanoma: is the initial biopsy representative of the final depth?

BACKGROUND

An accurate initial biopsy of the deepest portion of the melanoma is vital to the management of patients with melanomas.

OBJECTIVE

Our goal was to evaluate the accuracy of preliminary biopsies performed by a group of predominantly experienced dermatologists (n = 46/72).

METHODS

A total of 145 cases of cutaneous melanoma were examined retrospectively. We compared Breslow depth on preliminary biopsy with Breslow depth on subsequent excision. Was the initial diagnostic biopsy performed on the deepest part of the melanoma?

RESULTS

Of nonexcisional initial shave and punch biopsies, 88% were accurate, with Breslow depth greater than or equal to subsequent excision Breslow depth. Both superficial and deep shave biopsies were more accurate than punch biopsy for melanomas less than 1 mm. Excisional biopsy was found to be the most accurate method of biopsy.

CONCLUSIONS

Deep shave biopsy is preferable to superficial shave or punch biopsy for thin and intermediate depth (<2 mm) melanomas when an initial sample is taken for diagnosis instead of complete excision. We found that a group of predominantly experienced dermatologists accurately assessed the depth of invasive melanoma by use of a variety of initial biopsy types.

Computer-aided melanoma diagnosis

This article presents a snapshot of fast-moving research into the application of digital imaging technology to in vivo computer-aided diagnosis of early melanoma. It is written from the perspective of a researcher with a keen interest in bringing this technology to physicians' offices. The primary emphasis is on reviewing the existing literature, supplemented by unpublished material relating to a particular system and as yet unpublished research studies.

Non-invasive analysis of melanoma thickness by means of dermoscopy: a retrospective study

Epiluminescence microscopy (ELM), or dermatoscopy, is a non-invasive technique for the diagnosis of cutaneous melanoma that may play a role in the non-invasive, preoperative assessment of melanoma thickness. This study investigated the correlation between the frequency of appearance of some standard ELM criteria and the histological thickness of melanomas. In addition, the possible role of the total dermoscopic score (TDS) according to ABCD rule of dermoscopy as a predictor of melanoma thickness was analysed. The dermoscopic images of 84 cutaneous melanomas were retrospectively investigated to evaluate the presence of 10 standard ELM criteria, and for each lesion the TDS was established (with observers blinded as to the tumour thickness). A statistically significant association was found between the presence of an irregular pigment network and melanomas with a Breslow index equal to or lower than 0.75 mm (positive predictive value of 68%); in contrast, radial streaming, atypical vascular pattern and grey-blue areas were associated with melanomas > 0.75 mm (positive predictive values of 77%, 65% and 70%, respectively). Of the melanomas thinner than 0.76 mm, 82% showed a TDS lower than 6.80 (optimized cut-off point), while 79% of melanomas thicker than 0.75 mm had a TDS higher than 6.80 (chi2 = 30.815, P < 0.001); the positive predictive value of a TDS > 6.80 in the detection of lesions thicker than 0.75 mm was 79%. In conclusion, a statistically significant correlation does exist between some dermoscopic features and melanoma thickness. Both the mostly used dermoscopic methods (standard ELM pattern analysis and the ABCD rule of dermatoscopy) may provide useful information in the non-invasive assessment of melanoma thickness. However, their diagnostic performance is far from 100%; further studies are needed to investigate whether the combination of dermoscopy with other non-invasive approaches (e.g. sonometry) may result in an overall improvement in the diagnostic performance.

Dermatoscopy in the diagnosis of pigmented skin lesions: a new semiology for the dermatologist

Dermatoscopy or epiluminescence microscopy (ELM), is a noninvasive method that enables clinicians to evaluate fully--by means of a magnified oil immersion diascopy--numerous morphological features, not visible with the naked eye, which enhance the diagnosis of nearly all pigmented skin lesions. In recent years, a burst of research activity in this topic has been carried out, dealing with different aspects, and new frontiers, of this technique. First, a continuous refinement of dermatoscopic terminology is undertaken, paying particular attention to the diagnostic performance of dermatoscopy at peculiar anatomical sites and to the building of different dermatoscopic algorithms aimed at a simplified diagnosis of melanoma, even for less experienced observers. Another point of interest concerns the possible role of dermatoscopy in the pre-operative assessment of melanoma thickness. Finally, promising data about the role of digital equipment in the follow up of melanocytic skin lesions as well as in the automated diagnosis of pigmented skin lesions have been recently reported. This paper should enable readers to become familiar with the procedure and terminology of ELM in the diagnosis of pigmented skin lesions encouraging a greater understanding of different methods (pattern analysis, algorithms) in the diagnosis of melanoma using ELM.

Preoperative assessment of melanoma thickness by ABCD score of dermatoscopy

BACKGROUND

Epiluminescence microscopy is a useful tool for the noninvasive diagnosis of malignant melanoma based on criteria that have been correlated with specific histologic characteristics. Previous studies have also shown a good correlation between the frequency of some dermatoscopic criteria based on pattern analysis (pigment network, blue-gray areas, vascular pattern) and tumor thickness. This technique could be useful in the preoperative assessment of tumor thickness as an indication for sentinel node biopsy.

OBJECTIVE

Our purpose was to evaluate the possible role of the total dermatoscopy score (TDS) assigned to a series of lesions in accordance with the ABCD rule of dermatoscopy as a preoperative predictor of melanoma thickness.

METHODS

For 84 cutaneous melanomas (17 were in situ melanomas; 67 invasive cases with mean thickness 0. 93 mm; range, 0.2-3.9 mm; standard deviation, 0.63) consecutively excised at the Department of Dermatology of Florence, TDS was established by two observers blinded as to the tumor thickness. The performance of different cut-off points of TDS in the diagnosis of melanoma with Breslow's thickness more than 0.75 or 1.00 mm was investigated by receiver operating characteristic (ROC) analysis. Accuracy of classification was evaluated in terms of sensitivity, specificity, and area under ROC curves (AUC).

RESULTS

The TDS assigned to cutaneous melanomas by the ABCD rule increased with the thickness of the lesions from in situ melanomas to melanomas of intermediate thickness (0.75-1.50 mm). As a preoperative method for the detection of melanomas with a Breslow thickness greater than 0. 75 mm, a TDS cut-off point of 6.80 showed 80% sensitivity, 84% specificity, and 82% diagnostic accuracy (AUC value, 0.90). TDS performed better in the diagnosis of a thickness threshold of 0.75 than 1.00 mm (higher AUC value).

CONCLUSION

The TDS calculated by the ABCD rule of dermatoscopy-a simplified approach to dermatoscopic diagnosis of melanoma-provides useful information for the preoperative assessment of melanoma thickness greater than 0.75 mm.

Clinical and dermatoscopic criteria for the preoperative evaluation of cutaneous melanoma thickness

BACKGROUND

Melanoma thickness measured according to the Breslow method is used to determine surgical margin and in patient selection for sentinel node biopsy. Previous studies did not confirm the reliability of melanoma palpability for clinical prediction of tumor thickness. Recently we reported the usefulness of epiluminescence microscopy (dermatoscopy) for in vivo detection of the phases of melanoma progression, as well as tumor depth.

OBJECTIVE

Our purpose was to determine whether the combination of clinical and dermatoscopic criteria could increase the accuracy in preoperative evaluation of melanoma thickness with respect to the clinical elevation and dermatoscopic assessments considered separately.

METHODS

In a blind retrospective study, 122 cutaneous melanomas were studied to evaluate the presence of several clinical and dermatoscopic criteria and their relation with the histologic thickness. An algorithm of combined criteria was constructed and statistically assessed.

RESULTS

Combinations of palpability, diameter of more than 15 mm, pigment network, gray-blue areas, and atypical vascular pattern allowed correct prediction of thickness in 89% of melanomas when categorized in two groups of less than 0.76 mm and more than 0.75 mm thickness, compared with 75% using palpability, and 80% using dermatoscopic criteria. Lower values were obtained in the further subdivision of melanomas into groups of 0.76 to 1.5 mm and more than 1.5 mm thickness.

CONCLUSION

The combination of clinical and dermatoscopic criteria is a more precise guide for the preoperative evaluation of melanoma thickness than either is alone. However, further studies are needed to verify its applicability in establishing the surgical approach to cutaneous melanoma.