Robert H. Johr

Dermoscopic Evaluation of Amelanotic and Hypomelanotic Melanoma

OBJECTIVE To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma. DESIGN A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions. SETTING Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy. RESULTS The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

Accuracy of teledermatology for pigmented neoplasms

BACKGROUND Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma. OBJECTIVE We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology. METHODS We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed. RESULTS We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology. LIMITATIONS Nondiverse study population and relatively small number of melanomas were limitations. CONCLUSIONS In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

Dermoscopy: alternative melanocytic algorithms—the ABCD rule of dermatoscopy, menzies scoring method, and 7-point checklist

In the year 2000, the Second Consensus Meeting on Dermoscopy was held over the Internet. Experts from around the world were asked to evaluate melanocytic, nonmelanocytic, benign, and malignant skin lesions using pattern analysis, the ABCD rule of dermatoscopy, Menzies scoring method, and the 7-point checklist. One hundred twenty-eight digital dermoscopic images were randomly subdivided into a training set of 20 images in which the unifying concepts of pattern analysis, the ABCD rule of dermatoscopy, Menzies scoring method, and the 7-point check list were presented. Those melanocytic algorithms were then used to evaluate another 108 cases. The results of the Second Consensus Meeting were presented at the First World Congress of Dermoscopy held in Rome, Italy, March 2001 and in an atlas that outlined the results and illustrated all of the cases.1,2 One of the main conclusions from the Second Consensus Meeting was that the four melanocytic algorithms studied were all valid ways to evaluate pigmented skin lesions with dermoscopy. This article will present the unifying concepts of the ABCD rule of dermatoscopy, Menzies scoring method, and the 7-point checklist. Other less-well-known and studied dermoscopic algorithms will not be presented.3–5

The Diagnostic Performance of Expert Dermoscopists vs a Computer-Vision System on Small-Diameter Melanomas

OBJECTIVE To evaluate the performance of dermoscopists in diagnosing small pigmented skin lesions (diameter </= 6 mm) compared with an automatic multispectral computer-vision system. DESIGN Blinded comparison study. SETTING Dermatologic hospital-based clinics and private practice offices. Patients From a computerized skin imaging database of 990 small (</= 6-mm) pigmented skin lesions, all 49 melanomas from 49 patients were included in this study. Fifty randomly selected nonmelanomas from 46 patients served as a control. MAIN OUTCOME MEASURES Ten dermoscopists independently examined dermoscopic images of 99 pigmented skin lesions and decided whether they identified the lesions as melanoma and whether they would recommend biopsy to rule out melanoma. Diagnostic and biopsy sensitivity and specificity were computed and then compared with the results of the computer-vision system. RESULTS Dermoscopists were able to correctly identify small melanomas with an average diagnostic sensitivity of 39% and a specificity of 82% and recommended small melanomas for biopsy with a sensitivity of 71% and specificity of 49%, with only fair interobserver agreement (kappa = 0.31 for diagnosis and 0.34 for biopsy). In comparison, in recommending biopsy to rule out melanoma, the computer-vision system achieved 98% sensitivity and 44% specificity. CONCLUSIONS Differentiation of small melanomas from small benign pigmented lesions challenges even expert physicians. Computer-vision systems can facilitate early detection of small melanomas and may limit the number of biopsies to rule out melanoma performed on benign lesions.

Color atlas of melanocytic lesions of the skin

This atlas-like presentation covers the various faces of melanocytic skin lesions of cutaneous melanomas and other pigmented skin tumors. It encompasses the classical methods of morphology such as the clinical and dermoscopic examination and dermatopathology as well as the most up-to-date diagnostic approaches such as laser scanning in-vivo microscopy and automated diagnosis. The core of this book represents an atlas with excellent clinical, dermoscopic and histopathologic images on melanocytic nevi, various types of melanomas and relevant other pigmented skin tumors including basal-cell carcinomas. Each of these well illustrated entities is presented following the same structure characterized by definition, clinical and dermoscopic features, relevant clinical differential diagnosis as well as practical aspects of management. Core messages will recapitulate the most pertinent facets of each entity. This comprehensive up-to-date text informs the reader on all practical issues of the modern-day management of individuals with melanocytic skin lesions.

Dermoscopy Key Points: Recommendations from the International Dermoscopy Society

J. Bowling G. Argenziano A. Azenha J. Bandic R. Bergman A. Blum H. Cabo A. Di Stephani J. Grichnik A. Halpern R. Hofman-Wellenhof R. Johr H. Kittler A. Kopf J. Kreusch D. Langford J. Malvehy A. Marghoob S. Menzies F. Ozdemir K. Peris D. Piccolo M.A. Pizzichetta D. Polsky S. Puig H. Rabinovitz P. Rubegni T. Saida M. Scalvenzi S. Seidenari H.P. Soyer M. Tanaka I. Zalaudek R.P. Braun

Original articleAccuracy of teledermatology for nonpigmented neoplasms

BACKGROUND Studies of teledermatology utilizing the standard reference of histopathology are lacking. OBJECTIVE To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. METHODS This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. RESULTS Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. LIMITATIONS Non-diverse study population. CONCLUSIONS Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Eccrine porocarcinoma arising in a seborrheic keratosis evaluated with dermoscopy and treated with Mohs' technique.

A 78‐year‐old white woman returned for a routine 6‐month skin cancer examination. She had a history of actinic keratosis and multiple basal cell carcinomas. She had no personal or family history of dysplastic nevi or melanoma. The patient was asymptomatic and unaware of any new or changing skin lesions.

Interobserver accuracy of store and forward teledermatology for skin neoplasms

adjacent nonirradiated (ie, shielded) site. These specimens were bisected for CD determination and hematoxylin-eosin staining. A histologic examination showed mild superficial perivascular inflammatory lymphocytic infiltrates in the majority of the control group’s irradiated sites. Baseline CD could not be quantified in two subjects in the nonP leucotomosetreated group; they were excluded from the subsequent analysis. At two times the MED, average CD values in the non-P leucotomosetreated group increased by 217% over baseline, while values in the P leucotomosetreated decreased by 84% (P 1⁄4 .06). At three times the MED, those values increased 760% and 61%, respectively (P 1⁄4 .07). No interaction significance was found (P 1⁄4 .08). Pretreatment with P leucotomos showed a strong trend but failed to achieve statistical significance in preventing the increase of CD levels 24 hours after UVA irradiation. Although chronic UVA exposure has been associated with CD elevation, our findings showed increments in CD expression after acute UVA exposure. According to our interaction analysis, P leucotomos’ effect exhibited a trend towards preventing the increase of CD levels as the UVA dose increased. Except for the expected erythema after UVA irradiation, no treatment-related adverse events were recorded in any of the subjects. Although pretreatment with P leucotomos did not prevent the development of mild superficial perivascular inflammatory lymphocytic infiltrate in subjects irradiated with UVA, more biopsies in the control group (those not receiving P leucotomos; n 1⁄4 6) reported the development of the infiltrate after UVA irradiation compared with biopsy reports in the PL group (n1⁄4 5) after irradiation with UVA. In addition, all biopsies from adjacent nonirradiated (ie, shielded) sites reported normal skin (ie, no infiltrates). Although larger studies are needed to characterize P leucotomos’ role in photoaging, this pilot study’s findings suggest that P leucotomos may prevent UVAinduced skin photodamage possibly by preventing UVA-dependent mitochondrial DNA damage.

False-negative melanomas

It has been reported that amelanotic melanoma is the great masquerader; however, any melanoma has the potential to fool the most experienced clinician. It is not possible to make the diagnosis 100% of the time no matter what clinical aids one uses. Experienced clinicians can diagnose melanoma clinically 60–75% of the time. In a metaanalysis it was shown that the diagnostic accuracy can be improved by as much as 49% with dermoscopy. The sensitivity of clinical evaluation plus dermoscopy can be as high as 97%. As many as 15% of melanomas can be false negative, mimicking melanocytic and non-melanocytic lesions or non-melanoma skin cancers. At times, the only way to suspect the diagnosis is by finding clinical and/or dermoscopic changes over time. In general, false-negative melanoma incognito could be a solitary macule, papule, nodule, or plaque that can have a smooth or scaly surface with or without ulceration. Polymorphous lesions can be seen with cutaneous metastatic melanoma. A single relatively innocuous color or multiple colors can be present with various shades of black, brown, gray, or blue. The ABCD clinical Chapter IV.5