Pigmented nodular melanoma: the predictive value of dermoscopic features using multivariate analysis

Assessment of the Diagnostic Performance of Clinical Examinations and High-Frequency Ultrasound in Patients With Pigmented Skin Tumors

OBJECTIVES

To investigate whether the integration of high-frequency ultrasound (HFUS) to routine clinical examinations could improve diagnostic performance and management decision for pigmented skin tumors.

METHODS

Three general practitioners trained previously and a dermatologist independently assessed pigmented skin tumors and rendered management decision based on clinical examinations alone or clinical examinations integrating HFUS.

RESULTS

After integrating HFUS, the diagnostic area under the curve (AUC) (0.658-0.693 versus 0.848, all P < .05) and specificity (46.6-58.6% versus 89.7%, all P < .05) for pigmented skin malignancies were improved for general practitioners, meanwhile unnecessary biopsy rate reduced (42.9-53.6% versus 10.7%, P < .001). To the dermatologist, the diagnostic AUC (0.822 versus 0.949, P < .001), sensitivity (81.7% versus 96.7%, P = .012) and specificity (0.828 versus 0.931, P = .031) improved significantly, meanwhile both missed biopsy rate (14.5% versus 4.8%, P = .031) and unnecessary biopsy rate (19.6% versus 7.1%, P = .016) decreased. Additionally, the diagnostic performance of the general practitioner with integrating HFUS could be comparable with the dermatologist based on clinical examinations alone (all P > .05).

CONCLUSIONS

As a complementary tool of clinical examinations, HFUS could help physicians differentiate pigmented skin malignancies and manage decision.

Dermoscopy of haemosiderotic/aneurysmal dermatofibroma: A morphological study of 110 cases

BACKGROUND

Haemosiderotic and aneurysmal dermatofibromas are uncommon and frequently misdiagnosed lesions, which can be considered as different histopathological stages of the same tumour. A dermoscopic diagnosis testing accuracy has not been performed for these tumours to date.

OBJECTIVES

To determine the diagnostic significance of dermoscopic structures and patterns associated with haemosiderotic/ aneurysmal dermatofibromas in a large series.

METHODS

Dermoscopic images of histopathologically proven cases of 110 haemosiderotic/ aneurysmal dermatofibromas and 501 other tumours were collected. The frequency, sensitivity, specificity, positive predictive value and negative predictive value of the dermoscopic structures and patterns associated with these lesions were calculated.

RESULTS

Haemosiderotic/ aneurysmal dermatofibromas are mostly symmetric lesions (86.5%), and a prominent homogeneous area was present in 100% of them. The presence of vascular structures was very common (86.4%), and dotted vessels were predominant (58.2%). Shiny white structures were seen in 85.5% of lesions, while a peripheral delicate pigment network was present in 69.1%. The most significant pattern was the one composed of a prominent homogeneous area and peripheral delicate pigment network, which showed a specificity of 100% with a relatively good sensitivity (69.1%). All the patterns containing a peripheral delicate pigment network showed very good specificities, positive predictive values and negative predictive values. Those patterns without a peripheral delicate pigment network showed the highest sensitivities, but they showed a significant overlap with other tumours, mainly with melanoma.

CONCLUSIONS

Dermoscopy is helpful in improving the diagnostic accuracy of haemosiderotic/ aneurysmal dermatofibromas. However, there is a considerable dermoscopic overlap between these tumours and melanoma, specifically when the peripheral delicate pigment network is absent.

Dermoscopy for the Identification of Amelanotic Acral Melanoma

Acral lentiginous melanoma is commonly misdiagnosed, and when detected late it portends a poor prognosis. Acral lentiginous melanoma can be mistaken for verruca, pyogenic granuloma, poroma, an ulcer, or other benign skin conditions. Patients with acral skin growths often present initially to a podiatric physician or their primary care physician. It is at this point when the growth is triaged as benign or potentially malignant. Dermoscopy aids in this decision making. Historically, dermoscopy training has been geared toward dermatologists, but there is increasing recognition of the need for dermoscopy training in primary care and podiatric medicine. Dermoscopy is particularly helpful in pink (amelanotic) growths, which can lack the traditional clinical findings of melanoma. A literature review of acral melanoma and dermoscopy was performed in PubMed. We also describe a case of amelanotic acral melanoma in a 58-year-old with a rapidly enlarging painful mass on her heel. The lesion was initially thought to be a pyogenic granuloma and was treated with debridement (curettage). She was ultimately seen in the dermatology clinic, and the findings under dermoscopy were worrisome for amelanotic melanoma. Biopsy confirmed the diagnosis. The cancer metastasized, and the patient died less than 2 years later.

Evolution of the Clinical, Dermoscopic and Pathologic Diagnosis of Melanoma

The conventional narrative states that the steadily rising incidence of melanoma among fair-skinned Caucasian populations during the last decades is caused by excessive UV-exposure. There is, however, no doubt that other factors had a significant impact on the rising incidence of melanoma. Pre-1980s the clinical diagnosis of melanoma was based on gross criteria such as ulceration or bleeding. Melanomas were often diagnosed in advanced stages when the prognosis was grim. In the mid-1980s education campaigns such as the propagation of the ABCD criteria, which addressed health care professionals and the public alike, shifted the focus towards early recognition. Dermatoscopy, which became increasingly popular in the mid-1990s, improved the accuracy for the diagnosis of melanoma in comparison to inspection with the unaided eye, especially for flat and small lesions lacking ABCD criteria. At the same time, pathologists began to lower their thresholds, particularly for the diagnosis of melanoma in situ. The melanoma epidemic that followed was mainly driven by an increase in the number of in situ or microinvasive melanomas. In a few decades, the landscape shifted from an undercalling to an overcalling of melanomas, a development that is now met with increased criticism. The gold standard of melanoma diagnosis is still conventional pathology, which is faced with low to moderate interobserver agreement. New insights in the molecular landscape of melanoma did not translate into techniques for the reliable diagnosis of gray zone lesions including small lesions. The aim of this review is to put our current view of melanoma diagnosis in historical context and to provide a narrative synthesis of its evolution. Based on this narrative I will provide suggestions on how to rebuild the trust in melanoma diagnosis accuracy and in the benefit of early recognition.

Assessment of Diagnostic Accuracy of Dermoscopic Structures and Patterns Used in Melanoma Detection: A Systematic Review and Meta-analysis

Importance

Dermoscopy increases the diagnostic accuracy for melanoma. However, the accuracy of individual structures and patterns used in melanoma detection has not been systematically evaluated.

Objective

To assess the diagnostic accuracy of individual dermoscopic structures and patterns used in melanoma detection.

Data Sources

A search of Ovid Medline, Embase, Cochrane CENTRAL, Scopus, and Web of Science was conducted from inception to July 2020.

Study Selection

Studies evaluating the dermoscopic structures and patterns among melanomas in comparison with nonmelanoma lesions were included. Excluded were studies with fewer than 3 patients, studies in languages other than English or Spanish, studies not reporting dermoscopic structures per lesion type, and studies assessing only nail, mucosal, acral, facial, or metastatic melanomas or melanomas on chronically sun-damaged skin. Multiple reviewers applied these criteria, and 0.7% of studies met selection criteria.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline and Meta-analysis of Observational Studies in Epidemiology reporting guideline were followed. Guidelines were applied via independent extraction by multiple observers. Data were pooled using a random-effects model.

Main Outcomes and Measures

The prespecified outcome measures were diagnostic accuracy (sensitivity and specificity) and risk (odds ratio [OR]) of melanoma for the following dermoscopic structures/patterns: atypical dots/globules, atypical network, blue-white veil, negative network, off-centered blotch, peripheral-tan structureless areas, atypical vessels (eg, linear irregular, polymorphous), pseudopods, streaks, regression (ie, peppering, scarlike areas), shiny white structures, angulated lines, irregular pigmentation, and a multicomponent pattern.

Results

A total of 40 studies including 22 796 skin lesions and 5736 melanomas were evaluated. The structures and patterns with the highest ORs were shiny white structures (OR, 6.7; 95% CI, 2.5-17.9), pseudopods (OR, 6.7; 95% CI, 2.7-16.1), irregular pigmentation (OR, 6.4; 95% CI, 2.0-20.5), blue-white veil (OR, 6.3; 95% CI, 3.7-10.7), and peppering (OR, 6.3; 95% CI, 2.4-16.1). The structures with the highest specificity were pseudopods (97.3%; 95% CI, 94.3%-98.7%), shiny white structures (93.6%; 95% CI, 85.6%-97.3%), peppering (93.4%; 95% CI, 81.9%-97.8%), and streaks (92.1%; 95% CI, 88.4%-94.7%), whereas features with the highest sensitivity were irregular pigmentation (62.3%; 95% CI, 31.2%-85.8%), blue-white veil (60.6%; 95% CI, 46.7%-72.9%), atypical network (56.8%; 95% CI, 43.6%-69.2%), and a multicomponent pattern (53.7%; 95% CI, 40.4%-66.4%).

Conclusions and Relevance

The findings of this systematic review and meta-analysis support the diagnostic importance of dermoscopic structures associated with melanoma detection (eg, shiny white structures, blue-white veil), further corroborate the importance of the overall pattern, and may suggest a hierarchy in the significance of these structures and patterns.

Dermatoscopic features of thin (≤2 mm Breslow thickness) vs. thick (>2 mm Breslow thickness) nodular melanoma and predictors of nodular melanoma versus nodular non-melanoma tumours: a multicentric collaborative study by the International Dermoscopy Society

BACKGROUND

Thin nodular melanoma (NM) often lacks conspicuous melanoma-specific dermatoscopic criteria and escapes clinical detection until it progresses to a thicker and more advanced tumour.

OBJECTIVE

To investigate the dermatoscopic morphology of thin (≤2 mm Breslow thickness) vs. thick (>2 mm) NM and to identify dermatoscopic predictors of its differential diagnosis from other nodular tumours.

METHODS

Retrospective, morphological case-control study, conducted on behalf of the International Dermoscopy Society. Dermatoscopic images of NM and other nodular tumours from 19 skin cancer centres worldwide were collected and analysed.

RESULTS

Overall, 254 tumours were collected (69 NM of Breslow thickness ≤2 mm, 96 NM >2 mm and 89 non-melanoma nodular lesions). Light brown coloration (50.7%) and irregular brown dots/globules (42.0%) were most frequently observed in ≤2 mm NMs. Multivariate analysis revealed that dotted vessels (3.4-fold), white shiny streaks (2.9-fold) and irregular blue structureless area (2.4-fold) were predictors for thinner NM compared to non-melanoma nodular tumours. Overall, irregular blue structureless area (3.4-fold), dotted vessels (4.6-fold) and serpentine vessels (1.9-fold) were predictors of all NM compared to non-melanoma nodular lesions.

LIMITATIONS

Absence of a centralized, consensus pathology review and cases selected form tertiary centres maybe not reflecting the broader community.

CONCLUSIONS

Our study sheds light into the dermatoscopic morphology of thin NM in comparison to thicker NM and could provide useful clues for its differential diagnosis from other non-melanoma nodular tumours.

Dermoscopy of Melanoma and Non-melanoma Skin Cancers

Dermoscopy is a widely used non-invasive technique for diagnosing skin tumors. In melanocytic tumors, e.g., melanoma and basal cell carcinoma (BCC), the effectiveness of dermoscopic examination has been fully established over the past two decades. Moreover, dermoscopy has been used to diagnose non-melanocytic tumors. Here, we review novel findings from recent reports concerning dermoscopy of melanoma and non-melanoma skin cancers including BCC, sebaceous carcinoma, actinic keratosis, Bowen's disease, squamous cell carcinoma (SCC), Merkel cell carcinoma (MCC), extramammary Paget's disease (EMPD), and angiosarcoma.

Dermoscopic aspect of verrucous epidermal nevi: new findings

Background/aim

Verrucous epidermal nevi are cutaneous hamartomas with many clinical variants. Dermoscopic features of verrucous epidermal nevus have rarely been investigated. We aimed to identify dermoscopic findings of the entity which will facilitate the diagnostic process by reducing the use of invasive diagnostic methods.

Materials and methods

The study included the patients with histopathologically approved verrucous epidermal nevus. Clinical, dermoscopic, and histopathological features of the patients were retrospectively reviewed and the findings identified were recorded. Dermoscopic examination was performed with a polarized-light handheld dermoscope with 10-fold magnification.

Results

The most common dermoscopic features were thick brown circles, thick brown branched lines, and terminal hairs. The most common vessel pattern was dotted vessels. Branched thick brown lines, brown globules, brown dots forming lines, serpiginous brown dots, white and brown exophytic papillary structures, fine scale, thick adherent scale, and cerebriform structures were the other findings.

Conclusion

We observed many vascular and nonvascular dermoscopic findings which were not described previously for the entity. Dermoscopic examination of the verrucous epidermal nevi may lead to more reliable clinical interpretation and thus may reduce the need for histopathological investigation.

Application of different noninvasive diagnostic techniques used in HMME-PDT in the treatment of port wine stains

BACKGROUND

Hematoporphyrin monomethyl ether photodynamic therapy (HMME-PDT) is an effective method for treating port wine stains (PWS). However, methods to evaluate the treatment of HMME-PDT for PWS effectively and objectively are lacking.

OBJECTIVE

This study aimed to describe the different noninvasive diagnostic techniques used in the evaluation of treatment response to HMME-PDT for PWS.

METHODS

Thirty-one lesions of 22 patients with PWS were treated with HMME-PDT. Four noninvasive diagnostic techniques including VISIA-CR™ system, dermoscopy, high-frequency ultrasound (HFUS), and laser speckle contrast imaging (LSCI) were used to obtain standard radiographic data on skin color, skin thickness, blood vessel morphology, blood vessel distribution, and blood perfusion from lesions and surrounding normal skin before and after HMME-PDT.

RESULTS

The standard image pattern of VISIA-CR™ system showed color change in the lesions of PWS after HMME-PDT. RBX red image of VISIA-CR™ system showed that erythema was highly aggregated even in invisible lesions at baseline but decreased after HMME-PDT. The erythema index reduced value d was related to the efficacy rating (γ = 0.631, P < 0.05). Dermoscopy showed that the number of spot-like and irregular linear vessels increased, which was correlated with the increase in clinical classification. After HMME-PDT, vascular rupture was observed by dermoscopy. The response rate of lesions with vascular rupture was 100.00% (20/20). Moreover, the response rate of lesions without vascular rupture was 63.64% (7/11). Vascular rupture sign was correlated with better efficacy (P < 0.05). HFUS showed that the dermis of PWS thickened and was arranged loosely with scattered linear hypoechoic signal. After HMME-PDT, the dermal layer of the lesions became thinner with a decreased linear hypoechoic signal. The response rate of the lesions with linear hypoechoic signal was 76.92% (10/13), and that without linear hypoechoic signal was 94.44% (17/18). The lesions without linear hypoechoic signal in the dermis showed better efficacy (P < 0.05). In some lesions, LSCI showed high blood perfusion signal in PWS lesions and blood perfusion reduction after HMME-PDT.

CONCLUSION

VISIA-CR™ system can be used to observe not only visible but also invisible lesions of PWS. Moreover, lesions fading after HMME-PDT can be described objectively by VISIA-CR™ system. Dermoscopy played an important role in the clinical classification of PWS, including assessing vascular injury after HMME-PDT, guiding the adjustment of therapeutic dose, and selecting the end point of treatment. Both HFUS and LSCI can be used to assist treatment response evaluation of HMME-PDT.

Safety Profiles and Pharmacovigilance Considerations for Recently Patented Anticancer Drugs: Cutaneous Melanoma

BACKGROUND

Malignant melanoma is a skin cancer responsible for 90% of cutaneous cancer- related deaths. In recent years, breakthroughs in treatment strategy have revolutionized the prognosis in both early and advanced melanoma patients. In particular, treatment with monoclonal antibodies targeting co-inhibitory checkpoints or specific molecular pathways leads to a new era of promising options, by prolonging the survival time of these patients. Moreover, unlike the chemotherapy that was used until some time ago, these new drugs have a good and more manageable toxicity profile. However, because of the recent introduction in clinical practice of the new agents, there is a learning curve among physicians regarding early recognition and management of the associated side effects.

OBJECTIVES

The analysis of the toxicity profiles of the different agents currently studied for the treatment of early and advanced melanoma, and the description of several relevant recent patents in this field, are the aims of this review.

METHODS

This is a systematically conducted review based on current clinical guidelines and on international Pharmacovigilance databases (AERS-Eudravigilance - WHO Vigibase).

RESULTS

Our systematic analysis outlines a comprehensive overview of the pharmacology, clinical application and the safety of recent anticancer drugs to treat melanoma, which can be an essential instrument for health professionals and researchers.

CONCLUSION

The new oncological therapies against melanoma are based on increasingly specific biological and immunological targets. For this reason, the potential toxicities that are expected from patients would be less relevant than the systemic "classical" chemotherapy. However, the new therapies are not free from the risk of causing adverse reactions, some of which must be managed promptly and appropriately; moreover, the multiplicity of the metabolic pathways exposes the new target therapies to relevant potential interactions. This review can help to understand how important it is not to underestimate potential adverse drug reactions related to new targeted therapies.

Dermatoscopy of Neoplastic Skin Lesions: Recent Advances, Updates, and Revisions

OPINION STATEMENT

Dermatoscopy (dermoscopy) improves the diagnosis of benign and malignant cutaneous neoplasms in comparison with examination with the unaided eye and should be used routinely for all pigmented and non-pigmented cutaneous neoplasms. It is especially useful for the early stage of melanoma when melanoma-specific criteria are invisible to the unaided eye. Preselection by the unaided eye is therefore not recommended. The increased availability of polarized dermatoscopes, and the extended use of dermatoscopy in non-pigmented lesions led to the discovery of new criteria, and we recommend that lesions should be examined with polarized and non-polarized dermatoscopy. The "chaos and clues algorithm" is a good starting point for beginners because it is easy to use, accurate, and it works for all types of pigmented lesions not only for those melanocytic. Physicians, who use dermatoscopy routinely, should be aware of new clues for acral melanomas, nail matrix melanomas, melanoma in situ, and nodular melanoma. Dermatoscopy should also be used to distinguish between different subtypes of basal cell carcinoma and to discriminate highly from poorly differentiated squamous cell carcinomas to optimize therapy and management of non-melanoma skin cancer. One of the most exciting areas of research is the use of dermatoscopic images for machine learning and automated diagnosis. Convolutional neural networks trained with dermatoscopic images are able to diagnose pigmented lesions with the same accuracy as human experts. We humans should not be afraid of this new and exciting development because it will most likely lead to a peaceful and fruitful coexistence of human experts and decision support systems.

Performance of the "if in doubt, cut it out" rule for the management of nodular melanoma

BACKGROUND

The recognition of nodular melanoma is clinically challenging, and the diagnostic accuracy of dermoscopy and confocal microscopy is lower than for superficial spreading melanoma.

OBJECTIVES

To test a management strategy consisting in the excision of any nodular lesion that cannot be confidently and precisely classified as a benign tumor after clinical and dermoscopic examination.

METHODS

Clinical and dermoscopic images of excised nodular lesions were retrospectively collected and evaluated. The evaluators were asked to record the level of diagnostic confidence for each lesion, by declaring if they were confident or doubtful about the given diagnosis. The NNE (number needed to excise) value was used to evaluate the efficacy of the proposed method.

RESULTS

A total of 1,319 excised nodular lesions formed the study set. The NNE for any malignancy was 3.9 (634/164), while the NNE for melanoma was 13.2 (634/48). NNE for hypo and amelanotic melanoma was 27.3 (327/12).

CONCLUSIONS

Excising doubtful nodular lesions seems to be an effective management strategy not to miss nodular melanoma, resulting in an acceptable rate of unnecessary excision of benign lesions.

Nodular skin melanomas and dermatoscopic diagnostic therein

Aim. The study of dermatoscopic pattern characteristics of nodular melanoma with the use of modified Kittler’s pattern analysis. Materials and methods. Clinical and dermatoscopis images of 127 patients with histologically distinctive nodular form of skin melanoma were examined. Nonpolarized dermoscopy of nodular melanoma foci was carried out to patients. Interpretation of obtained dermatoscopic images was performed with the use of pattern analysis modified by Harold Kittler. Main results. The two most important dermatoscopic features of nodular melanoma that distinguish it from other clinical types of this malignant tumor were revealed in our investigation: 1) the prevalence of dermatoscopis images with one pattern (structureless); 2) the prevalence of “grey dots, circles, clods” and “black peripheral dots and clods” as main features of nodular melanoma.

In vivo reflectance confocal microscopy features of a melanoacanthoma

Efforts have been expended to evaluate the reflectance confocal microscopy (RCM) features of different clinical entities in order to more thoroughly delineate benign versus malignant features. In this way, RCM can help clinicians to be more selective in regard to undertaking appropriate skin biopsies and improving their benign to malignant ratio. Herein, we report a case of a histopathologically proven melanoacanthoma, a variant of seborrheic keratosis. There are scarce reports describing the RCM features of melanoacanthoma. Our case demonstrated RCM features that were suspicious for melanoma. More RCM images of this benign entity are needed to establish definitive diagnostic criteria.

Dermoscopy of difficult-to-diagnose Melanomas

Dermoscopy is a non-invasive procedure that allows the evaluation of cutaneous lesions, and is considered to be a useful tool that improves the diagnostic accuracy of melanoma. Many dermoscopic criteria of melanoma have been established and several algorithms have been created for melanoma detection. However, the recognition of some melanomas remains challenging. Melanomas on specific body sites, melanomas in patients with multiple atypical moles, and nodular melanomas represent the most difficult-to-recognize melanoma subtypes, since they typically lack the “classic” melanoma-specific criteria. This paper provides an update on dermoscopy of difficult-to-diagnose melanomas by summarizing the newest data. Lastly, we highlight the importance of digital dermoscopy in the follow-up of melanocytic lesions for the detection of incipient melanomas while maintaining a low excision rate.

Recent advances in dermoscopy

The use of dermoscopy has offered a new morphological dimension of skin lesions and has provided an effective diagnostic tool to differentiate melanoma from other benign or malignant skin tumors but also to support the clinical diagnosis in general dermatology. The aim of this article is to provide an overview of the most recent and important advances in the rising world of dermoscopy.