The dermatoscopic ABCD rule does not improve diagnostic accuracy of malignant melanoma

The dermatoscopic ABCD rule has been suggested to improve diagnostic performance regarding cutaneous malignant melanoma. Using this rule, a total dermatoscopy score is calculated from the presence of various dermatoscopic elements. A total dermatoscopy score above 4.75 signifies possible and 5.45 probable melanoma. We compared the diagnostic accuracy of dermatoscopy with and without the use of the ABCD rule. Furthermore, receiver operating characteristic analysis was performed for the ABCD rule. The area under the receiver operating characteristic curve was 0.854 (range 0.777-0.906) demonstrating that in 85.4% of the cases, cutaneous malignant melanomas were rated higher than the non-melanoma skin lesions. Sensitivity for the melanoma diagnosis was higher for simple dermatoscopy than when the ABCD rule was used (p<0.05). There was no difference in specificity when a total dermatoscopy score of 4.75 was used as cut-off point, but specificity was lower for simple dermatoscopy than when the total dermatoscopy score of 5.45 was used. Diagnostic accuracy was higher for simple dermatoscopy than for the ABCD rule (p<0.01). In conclusion, the dermatoscopic ABCD rule was not superior to simple dermatoscopy, and fewer malignant melanomas were identified with this rule.     

Prognostic classification of malignant melanoma by clinical criteria

In a retrospective study of 503 well-documented cases of primary malignant melanoma (stage I) clinical criteria were analysed for their prognostic relevance. The maximum elevation (in mm) of the tumour was found to be the most important single prognostic factor. There was a close association with tumour thickness, measured histologically by the method of Breslow (correlation coefficient = 0.73). A combination of elevation and three additional clinical criteria (site, nodule- or lesion-diameter, and surface defects such as erosion, ulceration or bleeding) allowed a further improvement in prognostic accuracy. This clinical classification into low-risk and high-risk melanomas was as effective as the use of tumour thickness measured histologically, and can therefore be used for the preoperative planning of treatment.     

Comparison of dermatoscopic ABCD rule and risk stratification in the diagnosis of malignant melanoma

For didactic and documentation purposes the dermatoscopic ABCD rule and the dermatoscopic risk stratification have been proposed. The aim of this investigation was to compare the ability of the 2 methods to separate patients with cutaneous malignant melanoma from individuals with other pigmented skin lesions. Three dermatologists, experienced users of dermatoscopy, assessed macroscopic clinical and dermatoscopic slides from 258 patients referred to the skin cancer outpatient clinic by the ABCD rule and risk stratification methods. Diagnostic performance of the 2 methods was compared by receiver operating characteristics curve analysis. When all pigmented skin lesions were compared, there was a trend for the observers to perform better using risk stratification. When only lesions with a well-defined pigment network were included, the diagnostic performance of the risk stratification method was superior to the dermatoscopic ABCD rule (areas under the receiver operating characteristics curve median 0.93 vs. 0.80, p<0.004) for all observers. The agreement between the 2 methods was moderate to substantial (kappa coefficient 0.53-0.62). More melanomas were identified when the rules were combined. The dermatoscopic ABCD rule has been accepted as a standard for identifying melanomas with the dermatoscope, but should be considered secondary to pigment network analysis.     

A proposal for improving multicolor FISH sensitivity in the diagnosis of malignant melanoma using new combined criteria

Fluorescence in situ hybridization (FISH) for the diagnosis of melanoma makes use of specific fluorescent probes to detect selected chromosomal alterations on paraffin-embedded tissue samples. To date, interpretation of FISH data has been based on numerical values generated by 2 different computational algorithms that of Abbott and that of Gerami. To further evaluate the value of FISH in the diagnosis of malignant melanoma, we selected 163 clinically and histologically unequivocal cases of malignant melanoma in a cohort of 575 melanocytic tumors and analyzed FISH data using the criteria of Abbott, Gerami, and new combined criteria. Depending on the used criteria, FISH was positive in the unequivocal malignant melanoma in 69.3% (113/163) of cases using the Abbott criteria, 74.2% (121/163) of cases using the Gerami criteria, and 82.2% (134/163) of cases using the combined criteria of Abbott and Gerami. Although use of all 3 criteria was associated with 100% FISH negativity in a cohort of 30 unequivocal benign melanocytic nevi, use of the combined criteria revealed more FISH-positive cases in ambiguous benign melanocytic lesions than the criteria of Abbott or Gerami alone: Abbott, 125 of 367; Gerami, 146 of 367; combined, 161 of 367. Furthermore, we show that 66% (8/12) of FISH-negative cases of unequivocal melanoma are positive when analyzed by array comparative genomic hybridization (aCGH), demonstrating that false-negative results remain despite the usage of the combined criteria for evaluation of FISH data. In these 8 FISH-negative aCGH-positive cases, copy number alterations were often located on chromosomes 9p, a chromosomal locus that is not targeted by the FISH probes currently used. In conclusion, the existing criteria for the evaluation of multicolor melanocytic FISH are limited by a nonnegligeable rate of false negativity that can be reduced by using newly proposed combined criteria but at the cost of increased detection of FISH positivity in ambiguous benign melanocytic lesions.     

Accuracy in the clinical diagnosis of malignant melanoma

The computerized database (1955 through 1982) of the Oncology Section of the Skin and Cancer Unit of New York (NY) University Medical Center includes data on 13,878 lesions. Of these lesions, 214 were diagnosed clinically and histologically as malignant melanoma (MM). An additional 51 lesions, diagnosed clinically as other than MMs, were found histologically to be MM. Seventy-nine lesions were clinically diagnosed as MM but were found histologically to be other entities. An analysis of the clinical diagnostic accuracy showed some improvement over the three periods studied (1955 through 1963, 1964 through 1973, and 1974 through 1982). Although the diagnostic accuracy for the best period (1974 through 1982) was only 64%, the diagnosis of MM was made in 84.5% of the histologically proved cases of MM, reflecting a high degree of sensitivity.     

The clinical features of malignant melanoma

The clinical diagnosis of malignant melanoma requires the following: an acceptance of the concept of "in situ" malignancy, both clinically and histologically; a high index of suspicion concerning any pigmented lesion; recalling the mnemonic "remember your A,B,C,D's"; and a knowledge of the clinical simulators of malignant melanoma. Prevention of death from malignant melanoma is possible through early diagnosis and prompt treatment of thin lesions (less than 0.76 mm in thickness). Such lesions have an excellent prognosis. This goal can be reached by carefully designed and implemented professional and public education programs such as those that have been introduced in Australia, West Germany, and the United States. Currently, new programs are being developed jointly by the American Academy of Dermatology and the American Cancer Society that are aimed at promoting self-examination of the skin as an adjunct to a routine physician examination as an additional means of detecting malignant melanoma at a time when it is wholly curable.     

早期诊断黑素瘤的无创方法

黑素瘤作为一种高度恶性的皮肤肿瘤,经早期诊断和治疗能够获得较高的存活率.目前黑素瘤的诊断无疑仍依赖于组织病理学方法,然而活检或手术切除是病理学诊断的必要条件.黑素细胞性皮肤病中,良性病变占绝大多数,如能通过其他方法早期鉴别,则可减少不必要的组织创伤.皮肤自我检查、皮肤镜、远程皮肤镜、激光共聚焦显微镜等无创方法均可用于鉴别良、恶性黑素性皮肤病,缩短以往诊断黑素瘤所需要的时间、简化其繁琐的过程.概述几种主要的无创方法早期诊断黑素瘤.     

Reproducibility of the clinical criteria (ABCDE rule) and dermatoscopic features (7FFM) for the diagnosis of malignant melanoma

Dermatoscopy improves the sensitivity and the specificity in the diagnosis of melanoma. Although the reproducibility of dermatoscopic features has been the subject of research, no study up to now has compared the reproducibility of dermatoscopic features to the reproducibility of the clinical criteria of the ABCDE rule. For this reason we decided to examine the reproducibility of the clinical ABCDE rule and of our diagnostic dermatoscopic method 7FFM, as well as of the individual criteria of both. A total of 73 dermatologists attended three dermatoscopic courses and examined a set of clinical and dermatoscopic slides of 50 pigmented skin tumors. Agreement % and K value for a kappa statistical analysis have been calculated to evaluate inter-rater reliability. The clinical and the dermatoscopic methods showed similar values of concordance: clinical score 2 mean agreement = 68%, mean K = 0.44; clinical score 3 mean agreement = 73%, mean K = 0.61; 7FFM mean agreement = 83%, mean K = 0.64. The clinical criteria A, B, and C and the dermatoscopic features of our method presented similar values of concordance as well: clinical criteria mean K range 0.35-0.25, dermatoscopic features mean K range 0.62-0.25. The dermatoscopic features of our method 7FFM show a good reproducibility after a short training program, similar to the reproducibility of the clinical criteria of the ABCDE rule for the diagnosis of melanoma.     

Further experience of public education for the early diagnosis of malignant melanoma in Leicestershire

Publicity campaigns alerting the public to the need for early attention to malignant melanoma (MM) were conducted in Leicestershire, England during the summers of 1987, 1988 and 1989. There was a marked, and statistically significant, rise in the number of referrals with good prognosis MMs in the period immediately after the first campaign. In the 2 subsequent years, despite further publicity campaigns, the number of MMs diagnosed per week remained lower than the postpublicity peak of 1986/87. The postpublicity rise was less marked in 1987/88 and 1988/89. In the next year (1989/90), in which there was no publicity campaign, the total number of MMs seen was higher than in 1988/89. Numbers of MMs seen per week remained relatively steady throughout the year. There was again no publicity in 1990/91, and the total number of MMs diagnosed was about the same as in the previous year. There was a rise in the number of MMs seen per week in what would have been the postpublicity period of this year. The initial results would he consistent with the initial postpublicity rise in numbers of MMs seen being made up of lesions seen‘early', that is, in 1986/87 and 1987/88. Since these lesions were seen earlier than they would have been had there been no publicity, the number of MMs seen in 1988/89 w as lower than it would otherwise-have been and the publicity effort appeared to have less effect. By 1989/90 and 1990/91 this effect seems to have been wearing off. It may be that, at least in low MM incidence areas like the UK, it is better to pulse public-education for the early diagnosis of melanoma rather than to use annual or continuous campaigns. However, longer-term experience, and the pooling of data between centres will be necessary to test this conclusion.     

UV-ray sensitivity of patients with malignant melanoma

In 77 patients with malignant melanoma and 74 control subjects without skin tumors caused by sunlight, the minimal erythema dosage (MED) in the UV-C and UV-B areas, immediate pigment darkening (IPD), and minimal tanning dose (MTD) were determined according to skin type. Direct (MED-UV-B, MED-UV-C) and inverse (IPD, MTD) correlations were established according to skin type. These parameters showed no differences between patients with malignant melanoma and the control group.     

Photography for the early diagnosis of malignant melanoma in patients with atypical moles.

Several articles have been published that carefully describe techniques for obtaining reliable photographic series of patients with the atypical mole syndrome. Four common methods of total body photography are described. Follow-up studies of the effectiveness of photodocumentation for patients with the atypical mole syndrome are reviewed.     

An evaluation of the revised seven-point checklist for the early diagnosis of cutaneous malignant melanoma

Summary The seven-point checklist has been widely advocated as a sensitive screening test for malignant melanoma. A number of groups have questioned the sensitivity of this system, especially in the detection of early lesions. We have assessed the sensitivity and specificity of the revised seven-point checklist when applied to lesions seen in our department over a 26-month period and compared it with the American ABCDE evaluation system. All melanomas ( n = 65) were detected using the revised seven-point checklist and all were found to have at least one of the three major criteria defined by that system. Five (7·7%) melanomas were not picked up by the ABCDE checklist. Of 100 randomly selected patients who attended the clinic during the same period, with clinically diagnosed benign pigmented lesions, 63 had at least one major feature of the revised seven-point checklist. Forty (62%) of the melanomas, compared with only (4%) of the benign lesions, had more than one major feature. This study confirms the sensitivity of the revised seven-point checklist in the diagnosis of cutaneous malignant melanoma.     

The seven features for melanoma: a new dermoscopic algorithm for the diagnosis of malignant melanoma.

The clinical diagnosis of melanoma has a mean sensitivity of 67%, dermoscopy or dermatoscopy is a non invasive technique which improves this sensitivity. Our purpose was to create a simple dermoscopic method for the diagnosis of melanoma useful in daily office practice. For this reason a training set of 218 cutaneous pigmented lesions was used and scored for 16 dermoscopic features: for each feature sensitivity, specificity and statistical significance were evaluated. The results were used to create a simple dermoscopic diagnostic method of only seven dermoscopic features (7FFM). The method was used to evaluate a test set of 713 pigmented skin lesions consecutively observed. The diagnostic dermoscopic method developed gave a sensitivity of 94.6%, a specificity of 85.5% and an efficiency of 87.6%. Our method improves the sensitivity in the diagnosis of melanoma and can be used for the screening of pigmented skin lesions.     

The pretherapeutic phase of malignant melanoma of the skin. Analysis and suggestions for improvements in early diagnosis

138 patients suffering from histologically proven malignant melanoma of the skin were questioned about the period of time that had elapsed between recognizing the tumor and seeing a doctor. The average time was 331 days, but there was considerable variation. The main reason for the delay in seeking medical advice was a lack of knowledge concerning the nature of malignant melanoma. The patient's social background was the determining factor in how much time went by until he saw a physician. 20% of the melanomas were coincidental findings. The time which elapsed between seeing a doctor and initiation of therapy was 179 days on the average. This period largely depended on the specialization of the physician and the kind of evaluation given. Our analysis should help to shorten the time which elapses between recognition of the tumor by the patient and initiation of treatment by the physician. A reduction of this period should improve the prognosis of malignant melanoma.     

Langerhans cell histiocytosis mimicking malignant melanoma: a diagnostic pitfall

Langerhans cell histiocytosis (LCH), especially with an involvement limited to the skin, is a rare entity in adults. In formulating a differential diagnosis of a solitary skin lesion, LCH is rarely considered. Morphologically, cells seen in LCH can mimic those seen in a melanocytic tumor; moreover, they both show S-100 protein reactivity with immunoperoxidase staining. A 63-year-old male presented to a dermatology clinic with a solitary hyperpigmented macule on his right calf. A biopsy specimen showed epithelioid cells within the dermis, singly and in small groups, surrounded and infiltrated by collections of histiocytes and lymphocytes. These cells were diffusely positive for S-100 and negative for Melan-A. A diagnosis of malignant melanoma, spitzoid variant, was rendered, and the patient was sent to our melanoma center for surgical treatment. On histologic examination, some of the lesional cells had reniform, vesicular nuclei with central grooves. Additional immunoperoxidase staining showed strong, diffuse positivity for CD1a, supporting the diagnosis of LCH. LCH is morphologically similar to and can be misdiagnosed as malignant melanoma. It is important to be aware of this pitfall and utilize immunohistochemical and ultrastructural analysis to achieve correct diagnosis.