Clinical accuracy of the diagnosis of cutaneous malignant melanoma

Diagnostic accuracy for melanoma was determined in a dedicated pigmented lesion clinic. We assessed the impact of duration of experience in dermatology and also the relationship between tumour thickness and accuracy of clinical diagnosis. We reviewed the histopathology request forms and reports for all biopsies generated by the Pigmented Lesion Clinic, Western Infirmary, Glasgow during 1992–94 inclusive. The clinic is staffed by two consultants, one senior registrar and one registrar. Diagnostic accuracy, index of suspicion, sensitivity, specificity and positive predictive value were calculated for the clinic overall, and for each grade of staff. One hundred and sixty-three lesions were diagnosed clinically as melanoma. A histopathological diagnosis of melanoma was made for 128 lesions during this period, 113 of which had been correctly diagnosed before surgery. The diagnostic accuracy for two dermatologists each with > 10 years experience in dermatology was 80%, with sensitivity of 91% and positive predictive value of 86%. Diagnostic accuracy rates for two senior registrars (each with 3–5 years experience) and six registrars (each with 1–2 years experience) were 62% and 56%, respectively. Thin and intermediate thickness melanomas generated the greatest inaccuracy irrespective of clinical experience, although registrars failed to recognize melanoma three times more often than the other groups. We report the diagnostic accuracy for melanoma by trained dermatologists to be higher than previously reported. In comparison with trainees, > 10 years experience in dermatology and exposure to more than 10 melanomas per year appears to be associated with greater diagnostic accuracy. Knowledge of the current clinical diagnostic accuracy at varying levels of experience is essential if the impact of training is to be evaluated. As pigmented lesions of virtually all types can be treated within dermatology departments, dermatologists are the appropriate first point of referral for suspected early melanoma.     

Seasons influence diagnosis and outcome of cutaneous melanoma

The effects of season changes on the diagnosis of cutaneous melanoma have already been concluded; however, its clinical significance has yet to be defined. The aim of this study was to assess the effects of seasons on both the diagnosis and outcome of melanoma. A total of 1258 adult Caucasian Turkish cutaneous melanoma patients who had been treated and followed up in a single tertiary cancer referral center were included in the study. The most frequently affected season was summer (29%) followed by spring (26.6%), autumn (23.1%), and winter (21.3%). Similarly, rate of the patients diagnosed in July compared to January was significantly higher (11% vs 6%). Most of the clinicopathological characteristics were not correlated with seasons. The 5‐year overall survival rate was significantly higher for patients diagnosed in August (81%) than other months, and especially January (47%) (P = .002 and P = .0001, respectively). Similarly, the patients of July (65%) survived longer than those of January (P = .02). Furthermore, similar favorable outcomes for summer (70%) compared to other seasons and winter (51%) were shown (P = .005 and P = .001, respectively). In conclusion, there are seasonal fluctuations in diagnosis of melanoma with a peak in summer, and those diagnosed in summer have favorable survival outcomes.     

Seasonal pattern of the diagnosis of cutaneous melanoma: a hospital-based study in a Mediterranean country

BACKGROUND: Several investigators have described a seasonal variation in the diagnosis of cutaneous melanoma. Limited data exist on the seasonality of melanoma diagnosis in Southern European countries. PATIENTS AND METHODS: The seasonal pattern of diagnosis was analyzed in 404 Greek patients diagnosed with cutaneous melanoma (CM) between 1996 and 2004. A summer-to-winter ratio was determined overall and in relation to gender, age, anatomic site, histopathologic type, and tumor thickness. RESULTS: The summer-to-winter ratio was 1.53 for all patients (95% CI [confidence interval]: 1.15-2.02) with a ratio of 1.83 for women (95% CI: 1.20-2.78) and 1.28 for men (95% CI: 0.87-1.88). A seasonal pattern of melanoma diagnosis was observed for patients younger than 50 years of age (1.70, 95% CI: 1.05-2.74) and between 50 and 69 years (1.64, 95% CI: 1.05-2.56), for melanoma located on the upper or lower extremities (2.50, 95% CI: 1.12-5.56 and 2.23, 95% CI: 1.19-4.18, respectively), for superficial spreading and nodular melanomas (1.73, 95% CI: 1.12-2.69 and 1.52 95% CI: 0.96-2.41) and for melanomas with a tumor thickness of 1-2 mm (1.69, 95% CI: 0.91-3.12) and > 4 mm (2.13, 95% CI: 1.04-4.35). CONCLUSIONS: No major differences were seen in the seasonal distribution of CM diagnosis in a Mediterranean population compared to previously reported results. A better ascertainment of the skin during the summer and an increased awareness due to the melanoma screening campaigns are the more likely reasons for the seasonality of melanoma diagnosis in Greece.     

Seasonal variations in the diagnosis of cutaneous melanoma

Seasonal patterns in diagnosis were examined in 7836 patients with cutaneous melanoma (clinical stage I and II) documented at the Department of Dermatology and Allergology at Ludwig-Maximilian-University in Munich, Germany, between 1977 and 2000. Of these patients, 2362 were first given a diagnosis in the summer months (June-August) and 1757 were first given a diagnosis in the winter months (December-February). A summer-to-winter ratio was determined for sex, age, anatomic tumor site, histopathologic subtype, and tumor thickness. The summer-to-winter ratio was 1.34 (95% confidence interval: 1.27-1.43) for all patients, with a ratio of 1.22 (95% confidence interval: 1.12-1.33) for men and 1.47 (95% confidence interval: 1.35-1.60) for women. The frequency of diagnosis of cutaneous melanoma was seasonal for all age classes, for all anatomic tumor sites, for all histopathologic subtypes except acrolentiginous melanomas, and for melanomas with a tumor thickness <3.0 mm. Comparing subgroups of the above-mentioned clinical and histopathologic parameters, significant differences could be observed for sex and anatomic tumor site. On the basis of this data, possible explanations for the diagnostic summer peak may be a greater awareness as a result of clothing habits in summertime or because of incurred sunburns in patients with skin type I and II, and the influence of public-health campaigns usually performed at the beginning of summer.     

Scurvy: a cutaneous clinical diagnosis

Two cases of scurvy diagnosed following presentation with a purpuric rash are presented. A 44-year-old man developed scurvy as a result of poor dietary intake of vitamin C. This occurred because of a number of factors. including poor dentition, diarrhoea, depression and benzodiazepine/narcotic dependence. A 69-year-old man with acute myeloid leukaemic transformation of myelodysplastic syndrome developed mucositis, nausea, vomiting and diarrhoea as complications of chemotherapy. This led to poor dietary intake and consequently scurvy. Both cases demonstrated specific and diagnostic cutaneous manifestations of scurvy, particularly perifollicular purpura, ecchymoses and coiled corkscrew hairs. The diagnosis was supported by specific diet history. Ascorbic acid tolerance test was used as a simple laboratory method to confirm the clinical diagnosis.     

Histologic features and sensitivity of diagnosis of clinically unsuspected cutaneous melanoma.

The purpose of this study was to assess the sensitivity of clinical diagnosis of cutaneous malignant melanoma and to evaluate histologic characteristics of lesions not clinically diagnosed as such. Of 1,784 cases of histologically proven cutaneous malignant melanoma submitted routinely to a university dermatopathology laboratory between 1985 and 1990, 583 (33%) were not clinically suspected. The overall sensitivity in clinical diagnosis was 67%. Histologic features evaluated included presence of melanin, pagetoid spread of melanocytes, degree of inflammation, regression, presence and degree of sun damage as evidenced by solar elastosis, presence of melanin in the cornified layer, and coexisting nevus cells. Melanomas clinically thought to be nevi had less solar elastosis and most frequently had associated nevus cells. Those thought to be basal cell carcinomas had less melanin in lesions and less melanin in the cornified layer, and most often had foci of regression. Lesions thought to be keratoses showed melanin in the cornified layer 70% of the time, more often than any other type of lesion. Melanoma may be unsuspected clinically in a significant number of cases and can be mistaken for less serious cutaneous neoplasms. Histologic features of these lesions correlated well with original clinical diagnoses.     

Gender and cutaneous melanoma

Current evidence suggesting that a patient's sex is relevant to the progression of cutaneous melanoma is largely epidemiological. Although databases of patients with melanomas have for many years shown a survival advantage for female patients with primary melanoma, it has been difficult to evaluate the contribution of other known prognostic variables such as thickness and site of the primary tumour, factors which also tend to be related to sex. In addition, there are data from a limited number of experimental studies and clinical trials which support the concept of female survival superiority in melanoma. This paper attempts to summarize the evidence for gender being an important factor in melanoma survival.     

Early diagnosis of cutaneous malignant melanoma at Lawrence Livermore National Laboratory

The Lawrence Livermore (Calif) National Laboratory (LLNL) has observed a threefold increase in incidence of cutaneous malignant melanoma (CMM) since 1972. A consultant pathologist reviewed 49 of 50 cases of CMM diagnosed from 1969 to 1984 and reclassified 4 cases; this did not significantly affect the elevated rate. A comparison of the thicknesses of CMM at LLNL from 1976 to 1984 with those from a nearby community histopathology laboratory showed that 74% of the LLNL cases were Clark level I or II, compared with 40% of the comparison laboratory cases. A matched-pair comparison controlling for age, sex, and year of diagnosis showed the LLNL cases were thinner in 58% of the pairs. The median thickness of CMMs at LLNL decreased faster than those from the comparison laboratory.     

Dermoscopy of cutaneous melanoma metastases: A color‐based pattern classification

Dermoscopic studies about cutaneous metastases of malignant melanoma (CMMM) are few. Our objective was to analyze the dermoscopic features of CMMM and propose a new dermoscopic pattern classification based on color pigmentation and some specific dermoscopic features. A retrospective evaluation of 150 dermoscopic images of CMMM taken from 40 patients was performed. One hundred CMMM images were individually evaluated by six dermatologists in order to classify them according to four dermoscopic patterns: (i) blue pattern; (ii) pink pattern; (iii) brown pattern; and (iv) mixed pattern. One hundred and fifty dermoscopic images including 50 CMMM and 100 benign lesions were evaluated by five dermatologists to calculate the accuracy of these patterns in the recognition of CMMM. An intra‐ and interobserver reproducibility agreement study between all different dermoscopic pattern classifications was performed. Seventy‐five percent of our cases of CMMM showed a monochromatic pattern. Light brown pigmented halo, peripheral gray spots and polymorphic atypical vessels were the most significant focal dermoscopic structures. The reproducibility of the color‐based dermoscopic pattern classification was superior to previous dermoscopic pattern classification. In summary, a dermoscopic pattern classification based on color pigmentation and some specific dermoscopic features may be useful in recognizing early cutaneous melanoma metastasis. Multicentric studies are recommended in order to lower the impact of interobserver variability.     

Epidemiology of cutaneous melanoma

Although intermittent intense solar exposure and genetic traits such as fair skin continue to be associated with the risk of developing cutaneous melanoma, these factors fail to account for much of the incidence. Suggestive evidence has increased speculation that viral agents, radiation, hormones, chemicals in the workplace, and dietary factors play some etiologic role.     

Mechanisms of tumour vascularization in cutaneous malignant melanoma: clinical implications

Malignant melanoma represents < 10% of all skin cancers but is responsible for the majority of skin‐cancer‐related deaths. Metastatic melanoma has historically been considered as one of the most therapeutically challenging malignancies. Fortunately, for the first time after decades of basic research and clinical investigation, new drugs have produced major clinical responses. Angiogenesis has been considered an important target for cancer treatment. Initial efforts have focused primarily on targeting endothelial and tumour‐related vascular endothelial growth factor signalling. Here, we review different mechanisms of tumour vascularization described in melanoma and discuss the potential clinical implications.     

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.     

A method for the diagnosis of primary cutaneous melanoma using surface microscopy

For a melanoma to be diagnosed, it must have neither of two morphological negative features and one or more of nine positive features. The negative features are symmetry of pattern and a single color. The positive features are blue-white veil, multiple brown dots, pseudopods, radial streaming, scar-like pigmentation, peripheral black dots or globules, five or six colors, multiple blue-gray dots, and a broadened network. This method gives a 92% sensitivity and 71% specificity for the diagnosis of melanoma.