Melanoma

A retrospective review of 182 cutaneous melanomas seen at King's College Hospital from 1970 to 1987 showed that surgeons saw much thicker melanomas (median 3.64 mm) when compared to dermatologists (median 1.14 mm). Surgeons saw a greater proportion of nodular melanomas, less superficial spreading melanomas, were less likely to make the correct clinical diagnosis, and were more likely to perform wide excisions for thin melanomas (less than 2 mm) when compared to dermatologists. General surgeons see a different group of melanoma patients compared to dermatologists and manage them differently from dermatologists working with plastic surgeons. There is a need for a combined approach for the diagnosis and management of cutaneous melanoma between specialists.     

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.     

Prognosis for cutaneous melanoma according to surgical department: comparative study at a tertiary care hospital

IntroductionSurgical treatment of melanoma is performed by dermatologists and general or plastic surgeons. It is not known whether the type of specialist treating the melanoma results in a different prognosis for these patients.Material and methodsA retrospective study was carried out on the epidemiological, clinical/histological and evolutional characteristics of all patients diagnosed with melanoma at Hospital Gregorio Marañón over a 10-year period (1994--2003). The differences by hospital department where the patients were treated (dermatology, general surgery and plastic surgery) were noted.ResultsOver 90 % of the patients with melanoma were treated by the Dermatology Department. The thickness of the tumors and the presence of histologic ulceration were significantly higher in the melanomas treated by general and plastic surgeons (p < 0.05). The differences in overall average survival (105, 55 and 77 months) and disease-free time (88, 24 and 51.3 months) in the melanomas operated on by dermatologists, general surgeons and plastic surgeons, respectively, were significant (p < 0.001).ConclusionsThis study confirms that there are significant differences in the clinical and histological characteristics and the life prognosis of patients with cutaneous melanoma treated by different specialists. The melanomas treated by general or plastic surgeons have usually been developing for a longer time, and therefore are thicker and more often ulcerated than those treated by dermatologists, resulting in a lower survival period. With appropriate medical and surgical training, dermatologists are the most suitable specialists for early diagnosis and treatment.     

Evaluation of the diagnosis of pigmented tumors of the skin and factors leading to a decision to excise. Dermatologists of the Postgraduate Association of Haute-Normandie]

INTRODUCTION: The necessity of excising melanomas characterized by a slight thickness at an early stage, leads dermatologists to remove pigmented lesions which do not correspond to melanomas. The aims of this study were: a) to prospectively assess the accuracy of melanoma diagnosis, b) to quantify the number of excisions performed according to the degree of melanoma suspicion, c) to determine the specific clinical sign or signs of relevant diagnostic value. PATIENTS AND METHODS: This study was conducted prospectively from January 1996 to August 1997 by dermatologists in private practice and dermatologists from a University Hospital staff. When it was decided to excise a pigmented lesion, a form was filled out choosing the most appropriate clinical diagnosis, the degree of melanoma suspicion, and clinical signs which lead to surgery. Based on histological findings as the reference, the sensitivity, specificity, accuracy of melanoma diagnosis and the kappa test that evaluates the concordance between clinical and histological diagnosis, were performed. The diagnostic value of clinical signs was assessed by variance analysis. RESULTS: Of the 353 excised lesions, 38 (10.7 p. 100) were identified as melanoma on histologic examination. The sensitivity, the specificity and diagnostic accuracy were: 79 p. 100, 94 p. 100 and 53 p. 100 respectively. The kappa test concordance between clinical and histological diagnosis was 0.66. Two hundred and two lesions (57 p. 100) were excised even though the clinical suspicion of melanoma was poorly considered. Only one of these 202 lesions was identified histologically as a true melanoma. Thirty seven (24.5 p. 100) of the 151 remaining excised lesions with an "average" or "strong" suspicion were true melanomas. The clinical signs considered, alone or associated, had a poor predictive positive value (< 38 p. 100). An analytical approach performed with a logistic model permitted the identification of two associated signs suggesting a best diagnostic value. DISCUSSION: This is the only study, to our knowledge, reported in the literature which prospectively assesses the sensitivity, specificity and concordance between clinical and histological diagnosis of melanoma. Results were considered from average to good. The originality of this study was to assess the number of pigmented lesions excised according to the degree of melanoma suspicion, suggesting the possibility of reducing the number of nevi removed when the melanoma risk was considered clinically poor. Finally, this study emphasizes the limits of clinical semiology and the need for future diagnostic methods in the assessment of melanoma.     

Pre-operative diagnosis of pigmented skin lesions: in vivo dermoscopy performs better than dermoscopy on photographic images

BACKGROUND: Epiluminescence microscopy (ELM) (dermoscopy, dermatoscopy) is a technique for non-invasive diagnosis of pigmented skin lesions that improves the diagnostic performance of dermatologists. Little is known about the possible influence of associated clinical features on the reliability of dermoscopic diagnosis during in vivo examination. OBJECTIVE: To compare diagnostic performance of in vivo dermoscopy (combined clinical and dermoscopic examination) with that of dermoscopy performed on photographic slides (pure dermoscopy). DESIGN: This case series comprised 256 pigmented skin lesions consecutively identified as suspicious or equivocal during examination in a general dermatological clinic. Clinical examination and in vivo dermoscopy were performed before excision by two trained dermatologists. The same observers carried out dermoscopy on photographic slides at a later time, and these three diagnostic classifications were reviewed together with the histological findings for the individual lesions. This was carried out in a university hospital. RESULTS: In vivo dermoscopy performed better than dermoscopy on photographic slides for classification of pigmented skin lesions compared with histological diagnosis, and both performed better than general clinical diagnosis. In vivo dermoscopic diagnosis of melanoma showed 98.1% sensitivity, 95.5% specificity and 96.1% diagnostic accuracy while dermoscopic diagnosis of melanoma on photographic slides was less reliable with 81.5% sensitivity, 86.7% specificity and 85.2% diagnostic accuracy. In particular, diagnosis of melanoma based on photographic slides led to nine false negative cases (three in situ, six invasive; thickness ranges 0.2-1.5 mm). CONCLUSIONS: In vivo dermoscopy, i.e. combined clinical and dermoscopic examination, is more reliable than dermoscopy on photographic slides. In clinical practice, therefore, in vivo dermoscopy cannot be considered independent from associated clinical characteristics of the lesions, which help the trained observer to reach a more precise classification. This may have implications on the reliability of ELM diagnosis made by an observer not fully trained in the clinical diagnosis of pigmented skin lesions or by a remote observer during digital ELM teleconsultation.     

Effect of lesion size on the diagnostic performance of dermoscopy in melanoma detection

BACKGROUND: Dermoscopy is able to correctly classify a higher number of melanomas than naked-eye examination. Little is known however about factors which may influence the diagnostic performance during practice. The aim of the study was to analyze the effect of size of the lesion on diagnostic performance of dermoscopy in melanoma detection. METHODS: Eight dermatologists examined clinical and, separately, clinical and dermoscopic (combined examination) images of 200 melanocytic lesions previously excised [64 melanomas, 24 in situ and 40 invasive (median thickness 0.30 mm) and 136 melanocytic nevi]. After examination, diagnostic performance was analyzed in accordance with the major diameter of the lesions divided into 3 groups, i.e. small (less than 6 mm), intermediate (between 6 and 9 mm) and large (10 mm or more) lesions. These groups were shown to be highly comparable concerning the microstaging of melanomas (median thickness value 0.30, 0.22 and 0.32 mm, respectively). RESULTS: Dermoscopy increased the diagnostic performance of naked-eye examination of both intermediate and large lesions [sensitivity value: +19.3 (p = 0.002) and +10.3 (p = 0.007); diagnostic accuracy value: +7.4 (p = 0.004) and +6.1 (p = 0.07)]. On the contrary, no statistically significant increase was found dealing with small lesions (sensitivity +3.7, p = 0.66; diagnostic accuracy -1.7, p = 0.55). CONCLUSIONS: The diagnostic improvement associated with the addition of dermoscopy to naked-eye examination is influenced by the size of the lesion, i.e. it is lacking with lesions up to 6 mm in diameter. The optimized use of dermoscopy in melanoma detection is obtained dealing with melanocytic lesions 6 mm in diameter or larger.     

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.     

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.     

Weight of decision-making impairs clinical assessment of melanocytic lesions

BACKGROUND AND OBJECTIVE: We studied the weight of decision-making on clinical assessment of melanocytic lesions judging benign, atypical, and malignant lesions; common mistakes; and total removal rates, comparing dermatologists with nondermatologists. METHODS: Of 11,246 histopathology specimens, 3,768 had a clinical assessment of melanocytic lesions. Histopathologic diagnosis served as the gold standard. RESULTS: Benign nevi were assessed most accurately (77%). Dermatologists assessed benign nevi better (p < .0001). The accuracy of clinical assessment in atypical nevi and melanoma was lower (23% and 42%, respectively). Seborrheic keratosis was the most common mistaken diagnosis. Complete removal of clinically benign nevi, atypical nevi, and melanoma was 84%, 90%, and 89%. Decision-making impaired clinical assessement of melanocytic lesions by 5% for dermatologists and 9% for nondermatologists. CONCLUSION: The accuracy of clinical assessment of melanocytic lesions is high for benign nevi, with dermatologists outperforming nondermatologists. Clinicians overestimated malignant potential. Complete removal was more frequent in suspicious lesions. Clinical decision-making impaired assessment by 5 to 9%.     

Melanoma outcomes for Medicare patients: association of stage and survival with detection by a dermatologist vs a nondermatologist

OBJECTIVE: To determine whether a difference in melanoma outcomes exists in the United States between tumors detected by dermatologists vs those detected by nondermatologists. DESIGN: Retrospective analysis of linked data from the Medicare enrollment and claims files from the Centers for Medicare and Medicaid Services and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database from 1991 to 1996. The registries are from 12 US sites. PATIENTS: A study sample comprised of 2020 subjects. MAIN OUTCOME MEASURES: Tumor characteristics (Breslow thickness and histologic ulceration), stage at diagnosis, and survival and mortality rates. RESULTS: Tumor detection by a dermatologist vs nondermatologist was associated with an earlier stage melanoma (stage 0, stage I, and stage II vs stage III and stage IV; chi(2) test, P<.01) and a thinner tumor (Breslow thickness, 0.86 mm vs 1.00 mm; P<.05). At all time points (6 months, 2 years, and 5 years), patients whose melanoma was detected by dermatologists had better survival rates (98%, 87%, and 74%, respectively, for those whose melanoma was detected by dermatologists vs 95%, 79%, and 69%, respectively, for nondermatologists; P<.05). Non-cancer-related mortality was similar for the 2 groups, but the patients whose tumors were detected by dermatologists had lower cancer-related mortality (13% vs 21%; P<.01) and overall mortality (29% vs 37%; P<.01). Multivariate analysis showed that age, sex, stage at diagnosis, and melanoma detection by a dermatologist were all significantly predictive of survival. CONCLUSIONS: Earlier stage melanoma and improved survival are associated with detection by a dermatologist rather than by a nondermatologist. Increasing access to dermatologists, particularly for older patients, may represent one approach to improving melanoma-related health outcomes.     

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.     

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.     

Melanoma in private practice: Do dermatologists make a difference?

Malignant melanoma is a major contributor to Australian morbidity and mortality. In this era of resource rationalisation, we seek to address the issue of whether routine full-skin examination by a dermatologist, rather than focussed examination of flagged lesions, will increase melanoma diagnosis. A retrospective chart review was undertaken between 1 July 2007 and 30 June 2008 in a private dermatology group practice in order to ascertain the number and characteristics of incidentally detected melanomas on routine skin examination. A total of 94 melanomas were detected during this 12-month period. Of these, 57 (60.6%) were incidentally detected by the dermatologist, 41 (71.9%) were in situ melanomas and 16 (28.1%) were invasive melanoma. Of the invasive lesions, 15 (94%) were 'thin' (less than 1.0 mm Breslow thickness). The majority of melanomas were found in men, and were distributed in areas of high cumulative sun exposure. Nine (9.6%) lesions were clinically misdiagnosed by the dermatologists and picked up on histopathology. This audit reaffirms the usefulness of routine full-skin examination by dermatologists in detecting de novo melanoma as part of the global strategy in reducing the burden of melanoma in Australia.     

The performance of SolarScan: an automated dermoscopy image analysis instrument for the diagnosis of primary melanoma

OBJECTIVE: To describe the diagnostic performance of SolarScan (Polartechnics Ltd, Sydney, Australia), an automated instrument for the diagnosis of primary melanoma. DESIGN: Images from a data set of 2430 lesions (382 were melanomas; median Breslow thickness, 0.36 mm) were divided into a training set and an independent test set at a ratio of approximately 2:1. A diagnostic algorithm (absolute diagnosis of melanoma vs benign lesion and estimated probability of melanoma) was developed and its performance described on the test set. High-quality clinical and dermoscopy images with a detailed patient history for 78 lesions (13 of which were melanomas) from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan. SETTING: Seven specialist referral centers and 2 general practice skin cancer clinics from 3 continents. Comparison between clinician diagnosis and SolarScan diagnosis was by 3 dermoscopy experts, 4 dermatologists, 3 trainee dermatologists, and 3 general practitioners. PATIENTS: Images of the melanocytic lesions were obtained from patients who required either excision or digital monitoring to exclude malignancy. MAIN OUTCOME MEASURES: Sensitivity, specificity, the area under the receiver operator characteristic curve, median probability for the diagnosis of melanoma, a direct comparison of SolarScan with diagnoses performed by humans, and interinstrument and intrainstrument reproducibility. RESULTS: The melanocytic-only diagnostic model was highly reproducible in the test set and gave a sensitivity of 91% (95% confidence interval [CI], 86%-96%) and specificity of 68% (95% CI, 64%-72%) for melanoma. SolarScan had comparable or superior sensitivity and specificity (85% vs 65%) compared with those of experts (90% vs 59%), dermatologists (81% vs 60%), trainees (85% vs 36%; P =.06), and general practitioners (62% vs 63%). The intraclass correlation coefficient of intrainstrument repeatability was 0.86 (95% CI, 0.83-0.88), indicating an excellent repeatability. There was no significant interinstrument variation (P = .80). CONCLUSIONS: SolarScan is a robust diagnostic instrument for pigmented or partially pigmented melanocytic lesions of the skin. Preliminary data suggest that its performance is comparable or superior to that of a range of clinician groups. However, these findings should be confirmed in a formal clinical trial.     

Developing indications for the use of sentinel lymph node biopsy and adjuvant high-dose interferon alfa-2b in melanoma

OBJECTIVES: To convene a multidisciplinary panel of dermatologists, surgical oncologists, and medical oncologists to formally review available data on the sentinel lymph node (SLN) biopsy procedure and high-dose adjuvant interferon alfa-2b therapy for patients with melanoma and to rate the "appropriateness," "inappropriateness," or "uncertainty" of the procedure and therapy to guide clinical decision making in practice. PARTICIPANTS: The panel comprised 13 specialists (4 dermatologists, 4 oncologists, and 5 surgeons) from geographically diverse areas who practiced in community-based settings (n = 8) and academic institutions (n = 5). Participants were chosen based on recommendations from the relevant specialty organizations. EVIDENCE: A formal literature review was conducted by investigators at Protocare Sciences Inc, Santa Monica, Calif, on the risks and benefits of performing an SLN biopsy in patients with stage I or II melanoma and adjuvant interferon alfa-2b therapy in patients with stage II or III disease. The MEDLINE database was searched from 1966 through July 2000, and supplemental information was obtained from various cancer societies and cancer research groups. Panel participants were queried on additional sources of relevant information. Unpublished, presented data were included in abstract form on 1 recently closed clinical trial. CONSENSUS PROCESS: The RAND/UCLA Appropriateness Method was used to review and rate multiple clinical scenarios for the use of SLN biopsy and interferon alfa-2b therapy. The consensus method did not force agreement. CONCLUSIONS: The panel rated 104 clinical scenarios and concluded that the SLN biopsy procedure was appropriate for primary melanomas deeper than 1.0 mm and for tumors 1 mm or less when histologic ulceration was present and/or classified as Clark level 4 or higher. The SLN biopsy was deemed inappropriate for nonulcerated Clark level 2 or 3 melanomas 0.75 mm or less in depth and uncertain in tumors 0.76 to 1.0 mm deep unless they were ulcerated or Clark level 4 or higher. Interferon alfa-2b therapy was deemed appropriate for patients with regional nodal and/or in-transit metastasis and for node-negative patients with primary melanomas deeper than 4 mm. The panel considered the use of interferon alfa-2b therapy uncertain in patients with ulcerated intermediate primary tumors (2.01-4.0 mm in depth) and inappropriate for node-negative patients with nonulcerated tumors less than 4.0 mm deep. Specialty-specific ratings were conducted as well.     

Clinical and dermatoscopic diagnosis of small pigmented skin lesions

Small pigmented skin lesions represent a new challenge for all physicians devoted to the early diagnosis of melanoma. The purpose of this prospective study was to establish the diagnostic value of the clinical and the dermatoscopic examinations in a population of 157 consecutive patients with 161 small (< or = 6 mm) pigmented lesions, recruited in a short time. Of these 161 lesions, 13 were thin melanomas (median thickness 0.49 mm). In this population, clinical evaluation produced a diagnostic sensitivity of 77% and a specificity of 74%. Dermatoscopy resulted in a sensitivity of 77% and in a specificity of 72%. Combining clinical and dermatoscopic evaluations all the melanomas were preoperatively recognised. The results of the present study stress the complementary role of clinical and dermatoscopic examinations. In particular, clinical evaluation remains of utmost importance in diagnosing melanoma. This concept must be stressed in the education and training of young dermatologists.     

La dermatoscopia como herramienta para inferir el Breslow del melanoma

Background and objectiveThe incidence of melanoma has increased significantly, and early diagnosis is the most effective way to reduce associated deaths. Dermoscopy increases diagnostic accuracy in melanoma and analysis of dermoscopic structures can help in the estimation of tumor thickness. The aim of this study was to analyze the influence of Breslow thickness on the dermoscopic characteristics of melanoma.Material and methodsObservational, cross-sectional study of patients with histologically confirmed melanoma and dermoscopic images of the tumor. The patients were divided into three groups: melanoma in situ, thin melanoma (≥ 1 mm Breslow thickness), and thick melanoma (≥ 1 mm Breslow thickness). Age, sex, tumor location, and histologic and dermoscopic characteristics were analyzed in all cases.ResultsWe studied 215 patients: 88 with melanoma in situ, 73 with thin melanoma, and 54 with thick melanoma. The frequency of the following dermoscopic features increased with increasing Breslow thickness: the blue-white veil (p < 0.001), white shiny structures (p < 0.001), and milky-red areas (p < 0.003). Angulated lines, by contrast, became less common with increasing thickness (p < 0.002).ConclusionsDermoscopy not only improves diagnostic accuracy for pigmented lesions but also helps in the preoperative assessment of Breslow thickness in melanoma.     

Melanoma diagnosis: Australian dermatologists' number needed to treat

A retrospective audit of melanoma clinical diagnoses was undertaken for a group of 35 Australian dermatologists. This was compared with the histological diagnoses. In a 1-year period, 195 of the 686 clinically suspicious lesions were histologically confirmed as melanoma. Therefore, the number needed to treat for histological referrals for melanoma is four for this group of dermatologists. In addition, we found that the sensitivity for the diagnosis of melanoma was 89.1% if we consider all lesions that are possibly clinically suspicious of melanoma. Our results suggest that the clinical diagnosis of melanoma may not be difficult for lesions that are clinically characteristic.     

Localized scleroderma (morphoea): thickness of sclerotic plaques as measured by 15 MHz pulsed ultrasound

The thickness of morphoea plaques was measured by A-mode ultrasound and compared to regional control measurements in the same individuals. The thickness of morphoea plaques was increased by 18-310% in 17 patients with one or a few morphoea plaques (p less than 0.01), and by 13-145% in 6 patients with generalized morphoea (p less than 0.05). The increase in thickness of morphoea plaques was local confined to the plaques. Ipsilateral and contralateral control measurements were not different, and measurements in a standard region (forearm) were not different from those in a group of healthy controls matched for sex and age. Plaques of clinically 'advanced' scleroderma were more thickened (p less than 0.01) than plaques of 'slight' scleroderma. The relative increase in thickness was larger (p less than 0.01) in skin with a habitual thickness of 0.8-1.1 mm. The habitual skin thickness on the extremities (mean 1.0 mm) was less (p less than 0.01) than on the trunk (mean 1.5 mm), and, consistently, plaques with 'advanced' scleroderma were more frequent (p less than 0.05) on the extremities. Ultrasound measurement of skin thickness was accurate with SD form 0.05-0.09 mm and coefficients of variation from 3-7% in reproducibility studies of typical morphoea plaques as well as normal appearing skin.     

Regular clinical dermatoscope use with training improves melanoma diagnosis by dermatologists

Dermatoscopy is not accepted by all dermatologists as a useful diagnostic tool. We set out to test if training followed by regular clinical use of dermatoscopes improved diagnostic accuracy in melanoma diagnosis. Six dermatologists who had not previously used dermatoscopes were studied before and after a 10‐month period of dermatoscope use with training and use of the Modified Pattern Analysis Diagnostic Algorithm. Diagnostic accuracy was assessed using test cards containing clinical and dermatoscopic photographs. The number of melanomas undiagnosed after training fell from 18 to 5 and the number potentially left unexcised fell from 18 to 3. The numbers of benign lesions potentially excised remained unchanged. The study shows that the use of dermatoscopes with training greatly increased the accuracy of diagnosis of melanoma by dermatologists. This practical study supports the use of dermatoscopy in pigmented‐lesion diagnosis and demonstrates how dermatoscopy training could be incorporated into UK specialist training programmes.