Br J Dermatol. 2004 Apr;150(4):706-14.
Related Articles, Links
Melanomas detected with the aid of total cutaneous photography.
Feit NE, Dusza SW, Marghoob AA.
Department of Dermatology, Memorial Sloan-Kettering Cancer Center, 160 East
53rd St, New York, NY 10022, USA.
BACKGROUND: Early detection of melanoma results in excision of thinner
melanomas, which are associated with better prognosis. Total cutaneous
photography provides a temporal comparison of lesions, which allows clinicians
and patients to recognize new and subtly changing lesions. OBJECTIVES: We
examined the utility of total cutaneous photography in detecting melanoma,
identified the reason for biopsy of suspicious lesions and determined who
detected new melanomas, the physician on follow-up examination or the patient
on self-examination. PATIENTS/METHODS: The charts of the 576 patients in
the total cutaneous photography database were reviewed. Twelve patients were
identified who had melanoma diagnosed with photographic assistance. Baseline
and prebiopsy photographs, dermatology clinic notes (115 patient visits) and
pathology reports for each biopsied lesion were reviewed. Histological diagnosis,
cause for biopsy, and whether the lesion was detected by the patient or physician,
was recorded for each of the biopsied lesions. Also noted were all the lesions that
concerned patients, the cause for concern, and whether these lesions were
biopsied. RESULTS: A total of 93 lesions were biopsied in these patients.
Twenty-seven (35%) of 77 melanocytic lesions were histologically diagnosed as
melanoma. The thickest melanoma found measured 1.1 mm, indicating a
favourable prognosis in our patients. Seventy-four per cent of the melanomas
were biopsied due to changes from baseline and 19% were biopsied because they
were new lesions. The changes noted were subtle and the lesions that proved to be
melanoma did not satisfy the classical clinical criteria for melanoma. Eight (30%)
of the melanomas were identified by patients on skin self-examination. Twentysix per cent of the lesions that concerned patients were not biopsied after
evaluation by a physician. CONCLUSIONS: We found that photographically
assisted follow-up helped detect new and subtly changing melanomas, which did
not satisfy the classical clinical features of melanoma. In addition,
photographically assisted follow-up helped detect nonmelanoma skin cancers.
Patient skin self-examination proved to be valuable, in that it complemented
physician follow-up examination in detecting melanomas. Photographic follow-up
was also valuable in avoiding unnecessary biopsy in suspicious, but stable lesions.
Total cutaneous photography therefore may be an effective way to increase the
sensitivity and specificity for detecting melanoma.
PMID: 15099367 [PubMed - indexed for MEDLINE]
1
2: J Am Acad Dermatol. 2004 Jan;50(1):15-20.
Related Articles, Links
Detection of melanomas in patients followed up with total cutaneous
examinations, total cutaneous photography, and dermoscopy.
Wang SQ, Kopf AW, Koenig K, Polsky D, Nudel K, Bart RS.
Department of Dermatology, University of Minnesota School of Medicine,
Minneapolis, USA.
BACKGROUND: Many factors have been identified as important determinants
that increase the risk of malignant melanoma (MM) developing. Patients with
classic atypical mole syndrome (CAMS) have multiple such factors and are
known to be at high risk for MMs developing. OBJECTIVE: We sought to
evaluate the risk for newly diagnosed MMs developing in patients with CAMS
and in a heterogeneous group of patients at high risk (ie, those with high-risk nonCAMS [HRNCAMS]) who had 1 or more risk factors: personal history of
nonmelanoma skin cancers; family history of melanoma; biopsy specimenconfirmed dysplastic nevi; and meeting 1 or 2 of the 3 CAMS criteria. We also
aimed to report our experience treating these patients at high risk with annual total
cutaneous examination, total cutaneous photography, and dermoscopy.
METHODS: Consecutive medical records from a private dermatology practice
were reviewed. A total of 258 patients were selected who fulfilled the criteria of
having: (1) total cutaneous photography as an aid for follow-up; (2) total
cutaneous examination at least once per year; (3) at least 6 months of clinical
follow-up; and (4) no personal history of melanomas. A total of 160 patients with
CAMS and 98 with HRNCAMS were included in this study. The 10-year risk for
MM developing in these 2 cohorts was computed using the Kaplan-Meier method.
RESULTS: In the CAMS cohort, 28 new MMs developed in 19 patients resulting
in a cumulative 10-year risk of 14% (95% confidence interval: 7-20). In the
HRNCAMS cohort, 10 new MMs developed in 9 patients, and the cumulative 10year risk was 10% (95% confidence interval: 2-17). The difference between the 2
groups was not statistically significant (P=.91). The MMs diagnosed in both
cohorts were either in situ or less than 1 mm in Breslow thickness. There were no
MM metastases or MM-related deaths in either cohort during a mean follow-up
period of 120 months for the CAMS and 98 months for the HRNCAMS group.
CONCLUSION: Both the patients with CAMS and HRNCAMS were at very high
risk for MMs developing. The combination of total cutaneous photography, total
cutaneous examination, and dermoscopy were used in treating our patients. No
MM 1 mm or greater in thickness developed during follow-up in either group.
PMID: 14699359 [PubMed - indexed for MEDLINE]
2
3: Cancer. 1995 Jan 15;75(2 Suppl):684-90.
Related Articles, Links
Techniques of cutaneous examination for the detection of skin
cancer.
Kopf AW, Salopek TG, Slade J, Marghoob AA, Bart RS.
Ronald O. Perelman Department of Dermatology, New York University School of
Medicine.
Skin cancers are the most common cancers in humans. The American Cancer
Society estimates that in the United States more than 700,000 new skin cancers
are diagnosed annually. Although the majority of nonmelanoma skin cancers
occur on visibly exposed anatomic areas, most malignant melanomas occur on
body sites obscured by clothing. The high mortality associated with advanced
melanomas emphasizes the importance of performing regular total cutaneous
examinations in all patients to detect early, easily curable lesions. A number of
techniques aid in these examinations: (1) physical and psychologic preparation of
the patient; (2) appropriate lighting and a suitable examination table; (3) when
indicated, use of Wood's light, dermoscopy, and photography. In addition, any
suspicious lesion should be biopsied promptly either in parte or in toto. Lastly, the
patient should be educated about the signs and symptoms of skin cancer, the role
of sunlight in causing skin cancer, and the need for sun avoidance and/or
protection. By heightening public awareness of the high incidence of cancers of
the skin and by emphasizing the need for routine examination of the entire
cutaneous surface, most cutaneous malignancies can be diagnosed early when
they can be cured by simple surgical procedures.
PMID: 7804995 [PubMed - indexed for MEDLINE]
4: Med J Aust. 1997 Aug 18;167(4):191-4.
Related Articles, Links
A high incidence of melanoma found in patients with multiple
dysplastic naevi by photographic surveillance.
Kelly JW, Yeatman JM, Regalia C, Mason G, Henham AP.
Victorian Melanoma Service, Alfred Hospital, Melbourne.
OBJECTIVES: (1) To assess the incidence of melanoma in a cohort of patients
with dysplastic melanocytic naevi (DMN) and the relationships between incident
melanomas and preexisting naevi and between melanoma risk and numbers of
DMN. (2) To examine the role of the patient versus the physician in detecting
3
melanoma and the relative value of surveillance versus prophylactic excision.
DESIGN: Prospective cohort study. PATIENTS AND SETTING: Two hundred
and seventy-eight adults, each with five or more DMN, were followed up for a
mean period of 42 months in a private dermatology practice. DMN were clinically
diagnosed. RESULTS: Twenty new melanomas were detected in 16 patients,
corresponding to an age-adjusted incidence of 1835/100000 person-years, 46
times the incidence in the general population. Eleven were detected because of
changes evident in comparison with baseline photographs and nine were detected
by patients or their partners. Thirteen of the 20 melanomas arose as new lesions
and only three from DMN. Melanoma risk rose with increasing numbers of DMN.
CONCLUSIONS: Increasing numbers of DMN are associated with increasing
melanoma risk. Surveillance (baseline photography and follow-up) enabled early
diagnosis of melanoma and was very much more cost-effective in preventing lifethreatening melanoma than prophylactic excision of DMN.
PMID: 9293264 [PubMed - indexed for MEDLINE]
5: Br J Dermatol. 2002 Feb;146(2):261-6.
Related Articles, Links
Melanoma detection rate and concordance between self-skin
examination and clinical evaluation in patients attending a
pigmented lesion clinic in Italy.
Carli P, De Giorgi V, Nardini P, Mannone F, Palli D, Giannotti B.
Department of Dermatology, University of Florence, Via degli Alfani, 37, 50121
Firenze, Italy. carli@unifi.it
BACKGROUND: The early diagnosis of melanoma is based on the collaboration
between dermatologists and family doctors, who filter subjects to be referred to a
pigmented lesion clinic (PLC). Following growing media coverage, there is
increasing concern in the general population about the risk of the 'changing mole',
resulting in a progressively increased workload in PLCs. AIM AND METHODS:
We investigated the causes of referral to a PLC in a series of 193 attendees seen
consecutively at the PLC of the University of Florence. Because the number of
naevi is the major risk factor for melanoma in Mediterranean populations, the
concordance between self-counting of naevi and the clinical evaluation of a PLC
dermatologist in order to classify high-risk individuals was also investigated.
RESULTS: Detection of a clinically suspicious lesion at dermatological
examination occurred in 13 of 193 subjects referred by general practitioners
(6.7%), with three melanomas confirmed histologically (overall detection rate:
three of 193, 1.6%). The positive predictive value of the 'presence of a suspicious
lesion', the cause of referral in 39.9% of subjects, was 9.1% when based on the
gold standard criterion represented by the clinical detection of a suspicious lesion
4
by the dermatologist and 3.8% based on the histological diagnosis of melanoma;
the negative predictive value was 94.8% (100% when based on the histological
diagnosis of melanoma), suggesting that the clinical detection of a suspicious
lesion in subjects with different causes of referral (such as risk factors for
melanoma, or the need to be reassured about moles) is unlikely. There was poor
agreement between self-evaluation based on the presence of multiple naevi and
the dermatological examination (gold standard) for both common and atypical
naevi. The highest concordance (kappa = 0.32, 95% confidence interval 0.200.43) was associated with a dichotomized count of naevi as up to 50 or more than
50 naevi. CONCLUSIONS: In order to reduce the PLC workload, the filtering
role of the family doctor needs to be improved, so that only subjects with a
specific suspicious lesion are referred to the PLC. The self-assessment of
melanoma risk based on the presence of multiple naevi was not reliable.
PMID: 11903237 [PubMed - indexed for MEDLINE]
6: Am J Prev Med. 2004 Feb;26(2):152-5.
Related Articles, Links
Patient adherence to skin self-examination. effect of nurse
intervention with photographs.
Oliveria SA, Dusza SW, Phelan DL, Ostroff JS, Berwick M, Halpern AC.
Dermatology Service, Department of Medicine, Memorial Sloan-Kettering
Cancer Center, New York, New York 10022, USA. oliveri1@mskcc.org
BACKGROUND: Results from a single case-control study suggest that skin selfexamination (SSE) has the potential to reduce mortality from melanoma by 63%.
Despite these encouraging results, SSE rates are low. Few prospective studies of
interventions to increase SSE in high-risk cohorts have been performed. The
purpose of this study was to assess the impact of a brief nurse-delivered
intervention using digital photographs on patients' adherence to performing SSE.
DESIGN SETTING/PARTICIPANTS: Patients at high risk for melanoma skin
cancer (five or more dysplastic nevi) (N=100) were recruited from the outpatient
Pigmented Lesion Clinic at Memorial Sloan-Kettering Cancer Center. All
participants had baseline whole-body digital photography as part of their clinical
evaluation. INTERVENTION: Patients were randomized: Group A (n =49)
received a teaching intervention (physician and nurse education module) with a
photo book (personal whole-body photographs compiled in the form of a booklet,
with nurse instruction on how to use the photographs); and Group B (n =51)
received the teaching intervention only without a photo book. MAIN
OUTCOMES/MEASURES: Self-administered questionnaires were provided at
three intervals: baseline, post-teaching intervention, and at the 4-month postbaseline visit. To assess adherence with SSE, patients were asked, "How many
5
times in the past 4 months did you (or someone else) usually, thoroughly examine
your skin?" RESULTS: In Group A (teaching intervention with photo book),
10.2% of the patients at baseline reported skin examination three or more times
during the past 4 months, while 61.2% reported skin examination three or more
times at the 4-month follow-up (p =0.039 for paired comparison). In Group B
(teaching intervention only), nearly 20% of the patients at baseline reported skin
examination three or more times during the past 4 months, while 37% reported
skin examination three or more times at the 4-month follow-up (p =0.63). The
increase in reported skin examination was compared between the two groups
(>51% v >17.6%, p =0.001). CONCLUSIONS: The results suggest that a brief
nurse-delivered intervention is effective at increasing patient adherence with SSE.
Utilizing digital photographs as an adjunct to screening appeared to increase
patient adherence to performing SSE.
Publication Types:


Clinical Trial
Randomized Controlled Trial
PMID: 14751328 [PubMed - indexed for MEDLINE]
7: Melanoma Res. 2004 Oct;14(5):403-7.
Related Articles, Links
Frequency and characteristics of melanomas missed at a pigmented
lesion clinic: a registry-based study.
Carli P, Nardini P, Crocetti E, De Giorgi V, Giannotti B.
Department of Dermatology, Centro per lo Studio e la Prevenzione Oncologica,
Florence, Italy. CARLI@unifi.it
To ensure the removal of all melanomas at an early phase, a number of benign
lesions are currently excised for diagnostic evaluation. Nevertheless, little is
known about the frequency of melanomas missed (neither recognized nor excised
for diagnostic verification) by early detection practices. This study aimed to
investigate the diagnostic performance of a specialized pigmented lesion clinic
(PLC) through linkage with a local cancer registry. In 1997, 1741 individuals
resident in the area of Florence and Prato, Italy, the catchment area of the Tuscany
Cancer Registry (RTT), were consecutively examined at a specialized PLC that
has been running since 1992 at the Department of Dermatology of Florence. The
outcomes of dermatological consultations retrieved from PLC case notes were
compared with all the diagnoses of both in situ and invasive melanoma recorded
by the RTT until 31 December 1999. The performance of the PLC in detecting
6
cutaneous melanoma was evaluated in terms of sensitivity, specificity and
predictive values, with the RTT data as the gold standard. In the population
examined at the PLC, 15 newly incident melanomas, all histologically
demonstrated, were recorded by the RTT. In 13 of the 15 cases, excision of the
lesion had been recommended by PLC staff, while two melanomas, one in situ
and one level II 0.60 mm thick invasive, were missed and were subsequently
excised 586 and 824 days, respectively, after the first PLC examination. The
clinical and dermoscopic features of the invasive lesion were in agreement with a
'featureless' melanoma, and lacked the well-established parameters of malignancy.
A total of 67 benign pigmented skin lesions were excised for diagnostic
evaluation. Thus the PLC showed a sensitivity in detecting cutaneous melanoma
of 86.7% (95% confidence interval [CI] 85.1-88.3%), a specificity of 95.4% (95%
CI 94.3-96.3%), a positive predictive value of 13.7% (95% CI 12.1-15.3%) and a
negative predictive value of 99.9% (95% CI 99.7-100.0%). The ratio of
melanomas to benign skin lesions excised was 1:5.1. In conclusion, specialized
examination of pigmented skin lesions at the PLC offered good level of diagnostic
performance, with an acceptable cost in terms of benign lesions removed and
overall a low risk of missing melanomas.
PMID: 15457097 [PubMed - indexed for MEDLINE]
8: Cancer. 2002 Oct 1;95(7):1562-8.
Related Articles, Links
Thin primary cutaneous melanomas: associated detection patterns,
lesion characteristics, and patient characteristics.
Schwartz JL, Wang TS, Hamilton TA, Lowe L, Sondak VK, Johnson TM.
Department of Dermatology, University of Michigan Medical Center and
University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
48109, USA. jennschw@umich.edu
BACKGROUND: Public awareness and education may lead to the detection of
thinner melanomas, which may result in a decrease in morbidity and mortality
rates. Which detection patterns, lesion, and patient characteristics are associated
with early detection? METHODS: Using the University of Michigan prospective
melanoma database, the detection patterns, lesion characteristics, and patient
characteristics of 1515 consecutive patients with in situ or invasive cutaneous
melanomas were reviewed. Tumor thickness (measured in millimeters) was
evaluated in relationship to detection patterns (patient, physician, spouse), lesion
characteristics (change in color, size, shape/elevation, ulceration, bleeding,
tenderness, itching), and patient characteristics (gender, skin type, number of
atypical and clinically benign nevi, history of sunburn, personal and family
history of melanoma). RESULTS: Patient characteristics associated with early
7
detection included female gender, at least one atypical nevus, greater than 20
clinically benign nevi, and/or a personal history of melanoma. Skin types I, II, and
III, a history of sunburn, and/or a family history of melanoma were also
associated with thinner lesions, but these associations were not statistically
significant. Lesion characteristics associated with earlier detection included a
change in color, size, shape/elevation, and/or itching. Physician-detected
melanomas were significantly thinner than patient or spouse-detected lesions.
CONCLUSIONS: Educational campaigns should include increasing melanoma
awareness in males and educating the public on the early signs and symptoms.
Education should be directed at both high and low-risk groups. Physicians should
consider performing total skin examinations routinely on patients. Although they
detect a relatively small percentage of all melanomas, physicians detect
significantly thinner lesions. Copyright 2002 American Cancer Society.DOI
10.1002/cncr.10880
PMID: 12237926 [PubMed - indexed for MEDLINE]
9: Br J Dermatol. 2002 Mar;146(3):481-4.
Related Articles, Links
Comment in:


Br J Dermatol. 2002 Dec;147(6):1278-9; author reply 1279.
Br J Dermatol. 2004 May;150(5):1040.
The use of the dermatoscope to identify early melanoma using the
three-colour test.
MacKie RM, Fleming C, McMahon AD, Jarrett P.
Department of Dermatology, University of Glasgow, Glasgow G12 8QQ, UK.
R.M.Mackie@clinmed.gla.ac.uk
BACKGROUND: There is continuing interest in pre-operative evaluation of
cutaneous pigmented lesions with the aim of differentiating early melanoma,
which requires excision from non-melanomatous pigmented lesions that may
safely be left untreated. OBJECTIVES: To establish, in the setting of a specialist
pigmented lesion clinic, if use of the hand-held dermatoscope can prevent
unnecessary excision of benign melanocytic pigmented lesions. METHODS: The
study was carried out by three dermatologists experienced in the use of the
dermatoscope. Patients had been referred by primary care physicians to the
pigmented lesion clinic and had melanocytic lesions considered by dermatologists
to merit excision on clinical grounds. A set of 74 sequentially observed lesions
referred for excision, 37 melanomas and 37 melanocytic naevi, was used as the
8
initial set and, thereafter, a second set of 52 lesions comprising 32 melanomas and
20 melanocytic naevi was used to validate conclusions drawn from the original
set. Clinical features such as appearance and history, and also dermatoscope
features were included in the assessment. RESULTS: In both sets of lesions, the
most powerful identifying feature of lesions subsequently shown on pathological
examination to be melanoma was the presence of three or more colours seen in
the lesion on dermatoscopy. In the initial set of lesions, the age of the patient, an
irregular edge and largest diameter of the lesion also contributed to diagnosis;
however, in the second set of lesions these variables contributed little additional
discriminatory value. The sensitivity and specificity of the three-colour
dermatoscopy test for melanoma vs. naevus were 92% and 51%, respectively.
CONCLUSIONS: The use of the dermatoscope three-colour test could reduce
excision of benign melanocytic naevi by 50%, and thus prevent both unnecessary
minor surgical workload and patient morbidity.
PMID: 11952549 [PubMed - indexed for MEDLINE]
10: J Am Acad Dermatol. 1996 Jun;34(6):971-8.
Related Articles, Links
Evaluation of the American Academy of Dermatology's National
Skin Cancer Early Detection and Screening Program.
Koh HK, Norton LA, Geller AC, Sun T, Rigel DS, Miller DR, Sikes RG,
Vigeland K, Bachenberg EU, Menon PA, Billon SF, Goldberg G,
Scarborough DA, Ramsdell WM, Muscarella VA, Lew RA.
Department of Dermatology, Boston University School of Medicine, MA, USA.
BACKGROUND: Increasing incidence and mortality rates from cutaneous
melanoma are a major public health concern. As part of a national effort to
enhance early detection of melanoma/skin cancer, the American Academy of
Dermatology (AAD) has sponsored an annual education and early detection
program that couples provision of skin cancer information to the general public
with almost 750,000 free skin cancer examinations (1985-1994). OBJECTIVE:
To begin to evaluate the impact of this effort, we determined the final pathology
diagnosis of persons attending the 1992-1994 programs who had a suspected
melanoma at the time of examination. METHODS: We directly contacted all such
persons by telephone or mail and received pathology reports from those who had
a subsequent biopsy. RESULTS: We contacted 96% of the 4458 persons with
such lesions among the 282,555 screenings in the 1992-1994 programs. We
obtained a final diagnosis for 72%, and the positive predictive value for
melanoma was 17%. Three hundred seventy-one melanomas were found in 364
persons. More than 98% had localized disease. More than 90% of the confirmed
melanomas with known histology were in situ or "thin" lesions (< or = 1.50 mm
thick). The median thickness of all melanomas was 0.30 mm. The 8.3% of AAD
9
cases with advanced melanoma (metastatic disease, regional disease, or lesions >
or = 1.51 mm) is a lower proportion than that reported by the 1990 Surveillance,
Epidemiology and End Result Registry. The rate of thickest lesions (> or = 4 mm)
and late-stage melanomas among all participants was 2.83 per 100,000
population. Of persons with a confirmed melanoma, 39% indicated (before their
examination) that without the free program, they would not have considered
having a physician examine their skin. CONCLUSION: The 1992-1994 free AAD
programs disseminated broad skin cancer educational messages, enabled
thousands to obtain a free expert skin cancer examination, and found mostly thin,
localized stage 1 melanomas (usually associated with a high projected 5-year
survival rate). Because biases impose possible limitations, future studies with
long-term follow-up and formal control groups should determine the impact of
early detection programs on melanoma mortality.
PMID: 8647990 [PubMed - indexed for MEDLINE]
11: J Eur Acad Dermatol Venereol. 2002 Jul;16(4):339-46.
Related Articles, Links
Pre-operative diagnosis of pigmented skin lesions: in vivo
dermoscopy performs better than dermoscopy on photographic
images.
Carli P, De Giorgi V, Argenziano G, Palli D, Giannotti B.
Department of Dermatology, University of Florence, Italy. CARLI@cesit1.unifi.it
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%
10
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.
PMID: 12224689 [PubMed - indexed for MEDLINE]
12: J Med Screen. 2002;9(3):128-32.
Related Articles, Links
A randomised trial of skin photography as an aid to screening skin
lesions in older males.
Hanrahan PF, D'Este CA, Menzies SW, Plummer T, Hersey P.
Oncology & Immunology Unit, Newcastle Mater Misericordiae Hospital, New
South Wales, Australia.
OBJECTIVES: We have previously shown that photographs assist in detection of
change in skin lesions and designed the present randomised population based trial
to assess the feasibility of photographs as an aid to management of skin cancers in
older men. SETTING: 1899 men over fifty, identified from the electoral roll in
two regions in New South Wales (NSW), Australia, were invited by mail to
participate. METHODS: A total of 973 of 1037 respondents were photographed
and randomised into intervention (participants given their photographs) or control
groups (photographs withheld by investigators). At one and two years from the
time of photography, all participants were advised to see their primary care
practitioner for a skin examination. Those in the intervention group were
examined with their photographs and those in the control group without their
photographs. RESULTS: The results indicated that the practitioners were more
likely to leave suspicious lesions in place for follow up observation (37% v 29%)
(p=0.006) and less likely to excise benign non pigmented lesions (20 v 32%).
There was little difference in excision rates for benign pigmented lesions (21% v
23%). Lesions excised were more likely to be non-melanoma skin cancer (58% v
42%) from patients who had photographs compared to those without photographs
(p=0.005). The use of skin photography resulted in a substantial savings due to
11
the reduced excision of benign lesions. CONCLUSIONS: These results suggest
that it would be feasible to conduct a large scale randomised trial to evaluate the
value of photography in early detection of melanoma and that such a trial could be
cost effective due to the reduced excision of benign skin lesions.
Publication Types:


Clinical Trial
Randomized Controlled Trial
PMID: 12370325 [PubMed - indexed for MEDLINE]
13: JAMA. 1999 Feb 17;281(7):640-3.
Related Articles, Links
Is physician detection associated with thinner melanomas?
Epstein DS, Lange JR, Gruber SB, Mofid M, Koch SE.
Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD,
USA.
CONTEXT: In cutaneous melanoma, tumor depth remains the best biologic
predictor of patient survival. Detection of prognostically favorable lesions may be
associated with improved survival in patients with melanoma. OBJECTIVE: To
determine melanoma detection patterns and relate them to tumor thickness.
DESIGN: Interview survey. SETTING AND PATIENTS: All patients with newly
detected primary cutaneous melanoma at the Melanoma Center, Johns Hopkins
Medical Institutions, between June 1995 and June 1997. MAIN OUTCOME
MEASURE: Tumor thickness grouped according to detection source. RESULTS:
Of the 102 patients (47 men, 55 women) in the study, the majority of melanomas
were self-detected (55%), followed by detection by physician (24%), spouse
(12%), and others (10%). Physicians were more likely to detect thinner lesions
than were patients who detected their own melanomas (median thickness, 0.23
mm vs 0.9 mm; P<.001). When grouped according to thickness, 11 (46%) of 24
physician-detected melanomas were in situ, vs only 8 (14%) of 56 patientdetected melanomas. Physician detection was associated with an increase in the
probability of detecting thinner (< or =0.75 mm) melanomas (relative risk, 4.2;
95% confidence interval, 1.4-11.1; P=.01). CONCLUSIONS: Thinner melanomas
are more likely to have been detected by physicians. Increased awareness by all
physicians may result in greater detection of early melanomas.
PMID: 10029126 [PubMed - indexed for MEDLINE]
12
14: J Med Screen. 1999;6(1):42-6.
Related Articles, Links
Screening for malignant melanoma using instant photography.
Edmondson PC, Curley RK, Marsden RA, Robinson D, Allaway SL, Willson
CD.
BUPA Health Screening Centre, London, UK.
OBJECTIVE: To assess the use of instant photography, in addition to clinical
grading, as a method of screening for malignant melanoma during routine health
examinations. SETTING: A health screening clinic with an average throughput of
about 12,000 patients a year. METHODS: Suspicious pigmented skin lesions
were judged clinically using the revised seven point checklist scoring system.
They were then photographed with a Polaroid camera and the prints were graded
independently by two consultant dermatologists with a special interest in
malignant melanoma. A copy of the print was also given to the patient to keep for
observation of any change in the lesion. RESULTS: Over a 45 month period
39,922 patients of both sexes were screened and 1052 skin lesions were clinically
assessed and photographed. Fourteen malignant melanomas were diagnosed--all,
except one, were thin lesions with a good prognosis. CONCLUSIONS: The
clinical opinions of non-dermatologists using the revised seven point checklist
proved disappointing in screening because of the large number of benign lesions
that were given high scores. Photography, on the other hand, detected 11
melanomas and succeeded in separating the majority of banal lesions from
potentially malignant ones, thus greatly reducing the need for specialist referral.
Nevertheless, three melanomas were missed on purely photographic grading,
which emphasises the danger of placing too much reliance solely on a two
dimensional image. Finally, the possession of a personal copy of the photograph
by the patient proved popular and led to a diagnosis of melanoma in two
instances. This procedure merits further study.
PMID: 10321371 [PubMed - indexed for MEDLINE]
15: Dermatol Surg. 2005 Feb;31(2):169-72.
Related Articles, Links
Examination of lesions (including dermoscopy) without contact with
the patient is associated with improper management in about 30%
of equivocal melanomas.
Carli P, Chiarugi A, De Giorgi V.
13
Department of Dermatology, University of Florence, Florence, Italy.
carli@unifi.it
BACKGROUND: In clinical practice, decisions regarding management of a
pigmented skin lesion are based on morphologic examination, as well as on
anamnestic, emotional, and medicolegal aspects. In some cases, the "ugly
duckling" sign may be an indication for excision of a morphologically featureless
melanoma. Therefore, examination of pigmented skin lesions based on clinical
and dermoscopic images, without contact with the patient, may be associated with
a not negligible risk of incorrect lesion management. OBJECTIVE: In this study,
we tried to assess to what extent lesion management based on purely morphologic
examination diverges from optimal management based on in vivo examination
with direct contact with the patient, lesion history, and clinical and dermoscopic
evaluation. METHODS: The study included clinical and dermoscopic images of
100 diagnostically equivocal pigmented lesions, including 20 early melanomas
and 5 pigmented basal cell carcinomas consecutively referred for surgery; the
images were reviewed by six dermatologists who specialize in melanoma
screening and were previously trained in dermoscopy. RESULTS: The percentage
of melanomas correctly classified was less than 50% both for naked eye and
combined examination. Regarding lesion management, only about 70% of
malignancies (melanomas and basal cell carcinomas) are correctly referred for
surgery by observers. Similar results have been obtained focusing on melanoma
(72.5%). CONCLUSION: Facing difficulties in diagnosing pigmented skin
tumors, lesion management based on the morphology of the lesion, even
including dermoscopic images, but without direct contact with the patient,
diverges greatly from the gold standard management established by face-to-face
examination and comports a not negligible risk of leaving a melanoma unexcised.
PMID: 15762209 [PubMed - indexed for MEDLINE]
16: Clin Exp Dermatol. 2004 Nov;29(6):593-6.
Related Articles, Links
Self-detected cutaneous melanomas in Italian patients.
Carli P, De Giorgi V, Palli D, Maurichi A, Mulas P, Orlandi C, Imberti G,
Stanganelli I, Soma P, Dioguardi D, Catricala C, Betti R, Paoli S, Bottoni U,
Lo Scocco G, Scalvenzi M, Giannotti B.
Department of Dermatology, University of Florence, Italy. CARLI@unifi.it
Self-detection of suspicious pigmented skin lesion combined with rapid referral to
dermatologic centres is the key strategy in the fight against melanoma. The
investigation of factors associated with pattern of detection of melanoma (self- vs.
nonself-detection) may be useful to refine educational strategies for the future.
14
We investigated the frequency of melanoma self-detection in a Mediterranean
population at intermediate melanoma risk. A multicentric survey identified 816
consecutive cases of cutaneous melanoma in the period January to December
2001 in 11 Italian clinical centres belonging to the Italian Multidisciplinary Group
on Melanoma. All patients filled a standardized questionnaire and were clinically
examined by expert dermatologists. Self-detected melanomas were 40.6%, while
the remaining lesions were detected by a dermatologist (18.5%), the family
physician (15.2%), other specialists (5%), the spouse (12.5%), a friend or
someone else (8.2%). Variables associated with self-detected melanomas were
female sex, young age, absence of atypical nevi, knowledge of the ABCD rule,
habit of performing skin self-examination. Self-detected melanomas did not differ
from nonself-detected tumours in term of lesion thickness; however, patients with
self-detected melanomas waited a longer period before having a diagnostic
confirmation (patient's delay) (> 3 months: odds ratio, 3.89; 95% confidence
interval, 2.74-5.53). In order to reduce the patients' delays, educational messages
should adequately stress the need for a prompt referral to a physician once a
suspicious pigmented lesion is self-detected.
Publication Types:

Multicenter Study
PMID: 15550129 [PubMed - indexed for MEDLINE]
17: Br J Dermatol. 2005 Jan;152(1):87-92.
Related Articles, Links
Surveillance of patients at high risk for cutaneous malignant
melanoma using digital dermoscopy.
Bauer J, Blum A, Strohhacker U, Garbe C.
Department of Dermatology, Eberhard-Karls-University, Liebermeisterstr. 25,
72076 Tubingen, Germany. mail@j-bauer.de
BACKGROUND: Dermoscopy has improved the sensitivity and specificity of
clinical diagnosis of melanoma from 60% to over 90%. However, in order not to
miss melanoma a certain percentage of suspicious but benign lesions has to be
excised. OBJECTIVES: To evaluate the dermoscopic changes and the rates of
excision in benign melanocytic naevi and cutaneous malignant melanoma in longterm follow-up of high-risk patients using digital dermoscopy. METHODS:
Digital dermoscopic images of 2015 atypical melanocytic naevi in 196 high-risk
patients were analysed retrospectively. Among others, the following data were
collected for each naevus: changes in surface area, overall architecture,
15
dermoscopic patterns and distribution of pigmentation. All tumours suspicious for
melanoma or showing asymmetrical changes were excised. RESULTS: During a
median follow-up time of 25 months 128 (6.4%) of all naevi showed changes in
size or architecture. Eighty-six per cent of all changes in patients who attended
more than one visit were observed at the first follow-up visit. Thirty-three lesions
showing changes were excised and two melanomas in situ and 31 melanocytic
naevi were diagnosed. CONCLUSIONS: Follow-up examinations using digital
dermoscopy revealed unchanged morphology in the large majority of melanocytic
naevi. Excisions were only performed in cases of asymmetrical growth,
asymmetrical changes of pigmentation, or development of dermoscopic features
indicative of melanoma. The ratio of 33 lesions excised in order to identify two
melanomas in situ seems reasonable and may be further reduced in future.
Publication Types:


Evaluation Studies
Review
PMID: 15656806 [PubMed - indexed for MEDLINE]
18: Melanoma Res. 2003 Apr;13(2):207-11.
Related Articles, Links
Relationship between cause of referral and diagnostic outcome in
pigmented lesion clinics: a multicentre survey of the Italian
Multidisciplinary Group on Melanoma (GIPMe).
Carli P, De Giorgi V, Betti R, Vergani R, Catricala C, Mariani G, Simonacci
M, Bettacchi A, Bottoni U, Lo Scocco G, Mulas P, Giannotti B.
Department of Dermatological Science, University of Florence, Italy.
CARLI@unifi.it
Pigmented lesion clinics (PLCs) are permanent units to which subjects presenting
with suspicious pigmented skin lesions can be rapidly referred and which can
provide a prompt response to an individual's concern about melanoma. However,
little is known about the melanoma detection rate in these clinics, in particular
with regard to intermediate risk populations. We report a survey involving more
than 1000 subjects consecutively referred by family doctors to six Italian PLCs.
Using a histological diagnosis of melanoma as the endpoint, the pooled melanoma
detection rate at these PLCs was 1.5% (one melanoma for diagnosed every 64
subjects examined), and the ratio between the number of melanomas and benign
lesions excised for diagnostic verification was 1: 5.8 (16 melanomas and 93
benign lesions). Almost all the melanomas (15 out of 16) were detected in
16
subjects who had requested referral for a specific doubtful lesion (group A) or for
the presence of melanoma risk factors (previous melanoma, large number of
common and atypical naevi, family history of melanoma) (group B). Only one
melanoma was detected amongst the 418 subjects seeking consultation for
concern about their moles (group C) (P = 0.004). The positive and negative
predictive values of the referral groups A and B combined were 2.5% and 99.7%,
respectively. Since the probability of detecting a melanoma in subjects referred
only for reassurance about their moles, which nevertheless represented 43% of the
subjects examined, is very low, an optimized role for PLCs in melanoma
prevention would be to limit consultation to subjects who present for examination
of a specific lesion or who have one or more risk factors for melanoma.
Publication Types:

Multicenter Study
PMID: 12690308 [PubMed - indexed for MEDLINE]
19: Cancer. 2001 Apr 15;91(8):1520-4.
Related Articles, Links
Earlier diagnosis of second primary melanoma confirms the benefits
of patient education and routine postoperative follow-up.
DiFronzo LA, Wanek LA, Morton DL.
Roy E. Coats Research Laboratories, John Wayne Cancer Institute at Saint John's
Health Center, Santa Monica, California, USA.
BACKGROUND: Rising health care costs have caused providers to question the
benefit of regular follow-up after treatment for patients with early stage cutaneous
melanoma. The authors hypothesized that routine reassessment and careful
education of these patients would facilitate earlier diagnosis of a subsequent
second primary melanoma, as reflected by reduced thickness of that lesion.
METHODS: A prospective melanoma data base was used to identify patients who
developed a second primary melanoma after treatment for American Joint
Committee on Cancer (AJCC) Stage I or II cutaneous melanoma. After excision
of the initial primary melanoma, all patients underwent routine biannual followup for new primary lesions. Follow-up consisted of a questionnaire and a
complete skin examination by a physician. In addition, patients were regularly
educated regarding the increased risk of developing a second melanoma. A paired
t test was used to examine AJCC stage, thickness, and level of invasion of the
initial melanoma compared with the second primary melanoma. RESULTS: Of
3310 patients with AJCC Stage I or II melanoma, 114 patients (3.4%) developed a
17
second primary melanoma. AJCC staging of both first and second melanomas was
available in 82 patients (72%). When the AJCC stages of first and second
melanomas were compared, 39 of 82 patients (48%) had lower stage second
primary lesions, and 41 (50%) had same-stage second primary lesions. The mean
tumor thickness was 1.32 +/- 1.02 mm for the initial melanoma, decreasing to
0.63 +/- 0.52 mm for the second melanoma; in fact, tumor thickness increased in
only 4 of 51 patients (8%) whose records contained data for both first and second
melanomas. Similarly, the level of invasion decreased in 60% of patients,
remained the same in 27% of patients, and increased in only 13% of patients. By
paired t test, the differences in AJCC stage, tumor thickness, and level of invasion
between first and second melanomas were each highly significant (P = 0.0001).
CONCLUSIONS: In this study, the second primary melanoma in patients with a
prior cutaneous melanoma was significantly thinner than the initial primary
lesion. This is evidence that careful follow-up and patient education allow earlier
diagnosis. All patients diagnosed with cutaneous melanoma should be counseled
regarding the risks of second melanoma and should undergo lifelong follow-up at
biannual intervals. Copyright 2001 American Cancer Society.
PMID: 11301400 [PubMed - indexed for MEDLINE]
20: J Am Acad Dermatol. 2000 Sep;43(3):467-76.
Related Articles, Links
Follow-up of melanocytic skin lesions with digital epiluminescence
microscopy: patterns of modifications observed in early melanoma,
atypical nevi, and common nevi.
Kittler H, Pehamberger H, Wolff K, Binder M.
Department of Dermatology, Division of General Dermatology, University of
Vienna Medical School, Austria. h.kittler@akh-wien.ac.at
BACKGROUND: Digital epiluminescence microscopy (DELM) has been
reported to be a useful technique for the follow-up of melanocytic nevi. One of
the promises of this technique is to identify modifications over time that indicate
impending or incipient malignancy and to facilitate surveillance of melanocytic
skin lesions, particularly in patients with multiple clinically atypical nevi.
OBJECTIVE: Our purpose was to report on patterns of modifications over time
observed in benign melanocytic skin lesions and melanoma. METHODS: A total
of 1862 sequentially recorded DELM images of melanocytic lesions from 202
patients (mean age, 36.1 years; 54.0% female patients) with multiple clinically
atypical nevi were included in the analysis. The median follow-up interval was
12. 6 months. Melanocytic lesions with substantial modifications over time
(enlargement, changes in shape, regression, color changes or appearance of ELM
structures known to be associated with melanoma) were excised and referred to
18
histopathologic examination. RESULTS: A total of 75 melanocytic skin lesions
(4.0%) from 52 patients (mean age, 33.3 years; 63.5% female patients) showed
substantial modifications over time and were excised and referred to
histopathologic examination. Eight changing lesions were histologically
diagnosed as early melanomas. These lesions frequently showed focal
enlargement associated with a change in shape as well as appearance of ELM
structures that are known to be associated with melanoma. In contrast, the
majority of benign changing lesions (common and atypical nevi) showed
symmetric enlargement without substantial structural ELM changes. Six of the 8
patients in whom melanoma developed were unaware of the fact that the lesion
had changed over time. CONCLUSION: We demonstrate that follow-up of
melanocytic lesions with DELM helps to identify patterns of morphologic
modifications typical for early melanoma. DELM may therefore serve as a useful
tool to improve the surveillance of patients with multiple atypical nevi.
PMID: 10954658 [PubMed - indexed for MEDLINE]
19