The significance of crystalline/chrysalis structures in the diagnosis of melanocytic and nonmelanocytic lesions

Dermatoscopic features of vulvar lichen sclerosus in children: A retrospective study

OBJECTIVES

To explore the dermoscopic features of lichen sclerosus in different parts of the external genitalia in children.

METHODS

A retrospective analysis of the dermoscopic features of 42 female children with vulvar lichen sclerosus treated in the Department of Dermatology of Shanxi Children's Hospital from January 2020 to May 2023.

RESULTS

Among the 42 female children, aged 3-14 years (mean: 7.24 ± 2.43 years), the duration of vulvar lichen sclerosus ranged from 3 months to 2 years (mean: 9.83 ± 4.93 months). Clinical lesions occurred in the labia minora in 18 cases (42.9%), labia majora in 38 cases (90.5%), posterior fourchette in 36 cases (85.7%), perianal area in 13 cases (31.0%), anterior fourchette in 17 cases (40.5%), clitoris in seven cases (16.7%), and interlabial sulcus in 11 cases (26.2%). Dermoscopic findings common in the labia majora included follicular keratotic plugs, cloverleaf-like structures, comedo-like openings, and linear vessels (p < .05); however, purple-red globules and patches and white linear streaks were more common in the posterior fourchette (p < .05), whereas dotted vessels were more common in the labia minora (p < .05).

CONCLUSIONS

Common dermoscopic findings in pediatric vulvar lichen sclerosus were yellow-white structureless areas, white linear streaks, follicular keratotic plugs, and cloverleaf-like structures; yellow-white structureless areas and white linear streaks showed the highest specificity. The dermoscopic findings varied among different affected areas, which provides a basis for further understanding of the characteristics of different sites of vulvar lichen sclerosus in the pediatric population.

Dermatoscopic shiny white structures in benign cutaneous tumours

The dermatoscopic characteristics of shiny white structures (SWS) in malignant skin tumours are well described, but data on benign skin neoplasms are scarce. To evaluate the dermatoscopic features of SWS in common benign tumours, we reviewed our database for histopathologically confirmed cases. Dermatoscopic images were evaluated for the presence of any type of SWS. Images with SWS were further analysed for their quantity, distribution and shape. Of 2420 evaluated benign tumours, 357 (14.8%) displayed SWS. The highest frequencies were observed in pyogenic granuloma (n = 62/100; 62%), angioma (n = 63/113; 55.8%) and adnexal tumours (n = 42/84; 50%). The lowest frequency was found in common naevi (n = 16/1032; 1.6%) and solar lentigo (n = 0). The presence of SWS was not associated with sex or anatomical location. SWS were usually diffuse and multiple. SWS may be present in a broad spectrum of benign tumours and therefore they should not be considered as de facto indicators of malignancy.

Ancillary techniques to improve dermoscopy specificity for skin cancer detection

Although the use of dermoscopy has markedly improved both the sensitivity and specificity for skin cancer detection, there is still opportunity for improvement. Ancillary techniques provide additional ways to assess a lesion with the aim of improving our diagnostic ability with little extra cost. Usage of these techniques can strengthen diagnosis and help reduce unnecessary biopsies of benign lesions.

Dermoscopy of Actinic Keratosis: Is There a True Differentiation between Non-Pigmented and Pigmented Lesions?

Dermoscopic features of actinic keratosis (AK) have been widely studied, but there is still little evidence for their diagnostic accuracy. Our study investigates whether established dermoscopic criteria are reliable predictors in differentiating non-pigmented actinic keratosis (NPAK) from pigmented actinic keratosis (PAK). For this purpose, dermoscopic images of 83 clinically diagnosed AK (45 NPAK, 38PAK) were examined, and the sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) were assessed. Features with statistical significance were the red pseudo-network (p = 0.02) for NPAK and the pigmented pseudo-network (p < 0.001) with a pigment intensity value even less than 10% for PAK (p = 0.001). Pigmented pseudo-network (Se: 89%, Sp: 77%, PPV: 77%, NPV: 89%) with a pigment intensity value of more than 10% (Se: 90%, Sp: 86%, PPV: 79%, NPV: 93%) had excellent diagnostic accuracy for PAK. Scale and widened follicular openings with yellowish dots surrounded by white circles were equally represented in both variants of AK. Linear wavy vessels and shiny streaks were more prominently observed in NPAK, as were rosettes in PAK, but these results failed to meet statistical significance. The red starburst pattern was near statistical significance for PAK. Therefore, pigmentation is the strongest dermoscopic predictor for the differentiation between NPAK and PAK.

Assessment of Diagnostic Accuracy of Dermoscopic Structures and Patterns Used in Melanoma Detection: A Systematic Review and Meta-analysis

Importance

Dermoscopy increases the diagnostic accuracy for melanoma. However, the accuracy of individual structures and patterns used in melanoma detection has not been systematically evaluated.

Objective

To assess the diagnostic accuracy of individual dermoscopic structures and patterns used in melanoma detection.

Data Sources

A search of Ovid Medline, Embase, Cochrane CENTRAL, Scopus, and Web of Science was conducted from inception to July 2020.

Study Selection

Studies evaluating the dermoscopic structures and patterns among melanomas in comparison with nonmelanoma lesions were included. Excluded were studies with fewer than 3 patients, studies in languages other than English or Spanish, studies not reporting dermoscopic structures per lesion type, and studies assessing only nail, mucosal, acral, facial, or metastatic melanomas or melanomas on chronically sun-damaged skin. Multiple reviewers applied these criteria, and 0.7% of studies met selection criteria.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline and Meta-analysis of Observational Studies in Epidemiology reporting guideline were followed. Guidelines were applied via independent extraction by multiple observers. Data were pooled using a random-effects model.

Main Outcomes and Measures

The prespecified outcome measures were diagnostic accuracy (sensitivity and specificity) and risk (odds ratio [OR]) of melanoma for the following dermoscopic structures/patterns: atypical dots/globules, atypical network, blue-white veil, negative network, off-centered blotch, peripheral-tan structureless areas, atypical vessels (eg, linear irregular, polymorphous), pseudopods, streaks, regression (ie, peppering, scarlike areas), shiny white structures, angulated lines, irregular pigmentation, and a multicomponent pattern.

Results

A total of 40 studies including 22 796 skin lesions and 5736 melanomas were evaluated. The structures and patterns with the highest ORs were shiny white structures (OR, 6.7; 95% CI, 2.5-17.9), pseudopods (OR, 6.7; 95% CI, 2.7-16.1), irregular pigmentation (OR, 6.4; 95% CI, 2.0-20.5), blue-white veil (OR, 6.3; 95% CI, 3.7-10.7), and peppering (OR, 6.3; 95% CI, 2.4-16.1). The structures with the highest specificity were pseudopods (97.3%; 95% CI, 94.3%-98.7%), shiny white structures (93.6%; 95% CI, 85.6%-97.3%), peppering (93.4%; 95% CI, 81.9%-97.8%), and streaks (92.1%; 95% CI, 88.4%-94.7%), whereas features with the highest sensitivity were irregular pigmentation (62.3%; 95% CI, 31.2%-85.8%), blue-white veil (60.6%; 95% CI, 46.7%-72.9%), atypical network (56.8%; 95% CI, 43.6%-69.2%), and a multicomponent pattern (53.7%; 95% CI, 40.4%-66.4%).

Conclusions and Relevance

The findings of this systematic review and meta-analysis support the diagnostic importance of dermoscopic structures associated with melanoma detection (eg, shiny white structures, blue-white veil), further corroborate the importance of the overall pattern, and may suggest a hierarchy in the significance of these structures and patterns.

Novel Insights for Patients with Multiple Basal Cell Carcinomas and Tumors at High-Risk for Recurrence: Risk Factors, Clinical Morphology, and Dermatoscopy

INTRODUCTION

Basal cell carcinoma (BCC) quite frequently presents as multiple tumors in individual patients. Neoplasm's risk factors for local recurrence have a critical impact on therapeutic management.

OBJECTIVE

To detect risk factors for multiple BCCs (mBCC) in individual patients and to describe clinical and dermatoscopic features of low- and high-risk tumors.

MATERIALS & METHODS

Our study included 225 patients with 304 surgically excised primary BCCs. All patients' medical history and demographics were recorded. Clinical and dermatoscopic images of BCCs were evaluated for predefined criteria and statistical analyses were performed.

RESULTS

Grade II-III sunburns before adulthood (OR 2.146, p = 0.031) and a personal history of BCC (OR 3.403, p < 0.001) were the major predisposing factors for mBCC. Clinically obvious white color (OR 3.168, p < 0.001) and dermatoscopic detection of white shiny lines (OR 2.085, p = 0.025) represented strongly prognostic variables of high-risk BCC. Similarly, extensive clinico-dermatoscopic ulceration (up to 9.2-fold) and nodular morphology (3.6-fold) raise the possibility for high-risk BCC. On the contrary, dermatoscopic evidence of blue-black coloration had a negative prognostic value for high-risk neoplasms (light OR 0.269, p < 0.001/partial OR 0.198, p = 0.001).

CONCLUSIONS

Profiling of mBCC patients and a thorough knowledge of high-risk tumors' clinico-dermatoscopic morphology could provide physicians with important information towards prevention of this neoplasm.

The differences in clinical and dermoscopic features between in situ and invasive nevus-associated melanomas and de novo melanomas

BACKGROUND

Nevus-associated melanomas (NAM) account for 30% of all melanomas and are associated with younger age and with thinner Breslow thickness. Previous studies of NAM dermoscopy found conflicting results.

OBJECTIVE

To compare the clinical and dermoscopic features of NAM and de novo melanomas (DNM), stratified by melanoma thickness, in a relatively large cohort of patients.

METHODS

A cross-sectional study of all melanomas biopsied between 2004 and 2019 at a large cancer centre. Lesions were categorized as in situ and invasive NAM or DNM. Dermoscopic images were reviewed and annotated. Associations between melanoma subtype and dermoscopic features were analysed via logistic regression modelling. Bivariate analyses were conducted using non-parametric bootstrap and chi-squared methods.

RESULTS

The study included 160 NAM (86 in situ and 74 invasive) and 218 DNM (109 in situ and 109 invasive). NAM were associated with younger age, greater likelihood of being present on the torso, and thinner Breslow thickness. NAM were 2.5 times more likely to show a negative pigment network than DNM. In situ NAM were 2.1 and two times more likely to display dermoscopic area without definable structures and tan structureless areas than DNM, respectively. In situ melanomas were more likely to present a pigment network, and invasive melanomas more commonly presented scar-like depigmentation and shiny white structures. Streaks, blotches and shiny white structures were associated with deeper Breslow depth.

CONCLUSIONS

Even though the nevus component of NAM could not be identified dermoscopically in the current series, negative pigment network, tan structureless areas and areas without definable structures are dermoscopic clues for NAM.

Association of Multiple Aggregated Yellow-White Globules With Nonpigmented Basal Cell Carcinoma

Importance

Basal cell carcinoma (BCC) is the most common skin cancer. Dermoscopic imaging has improved diagnostic accuracy; however, diagnosis of nonpigmented BCC remains limited to arborizing vessels, ulceration, and shiny white structures.

Objective

To assess multiple aggregated yellow-white (MAY) globules as a diagnostic feature for BCC.

Design, Setting, and Participants

In this retrospective, single-center, case-control study, nonpigmented skin tumors, determined clinically, were identified from a database of lesions consecutively biopsied during a 7-year period (January 1, 2009, to December 31, 2015). A subset of tumors was prospectively diagnosed, and reflectance confocal microscopy, optical coherence tomography, and histopathologic correlation were performed. Data analysis was conducted from July 1 to September 31, 2019.

Exposures

Investigators evaluated for the presence or absence of known dermoscopic criteria. MAY globules were defined as aggregated, white-yellow structures visualized in polarized and nonpolarized light.

Main Outcomes and Measures

The primary outcome was the diagnostic accuracy of MAY globules for the diagnosis of BCC. Secondary objectives included the association with BCC location and subtype. Interrater agreement was estimated.

Results

A total of 656 nonpigmented lesions from 643 patients (mean [SD] age, 63.1 [14.9] years; 381 [58.1%] male) were included. In all, 194 lesions (29.6%) were located on the head and neck. A total of 291 (44.4%) were BCCs. MAY globules were seen in 61 of 291 BCC cases (21.0%) and in 3 of 365 other diagnoses (0.8%) (P < .001). The odds ratio for diagnosis of BCC was 32.0 (96% CI, 9.9-103.2). The presence of MAY globules was associated with a diagnosis of histologic high-risk BCC (odds ratio, 6.5; 95% CI, 3.1-14.3). The structure was never seen in cases of superficial BCCs.

Conclusions and Relevance

The findings suggest that MAY globules may have utility as a new BCC dermoscopic criterion with a high specificity. MAY globules were negatively associated with superficial BCC and positively associated with deeper-seated, histologic, higher-grade tumor subtypes.

Heterogeneity in the linear shiny white structures in melanomas seen with polarized light according to histopathological association: Cross-sectional observational study in 118 cutaneous melanomas

Polarized dermoscopy enables visualization of linear shiny white structures in melanomas, thought to be due to the existence of fibrosis in the dermis. Our objective was to establish the existence of two types of linear shiny white structures and assess their association with different histological structures. We performed a cross-sectional study including all non-acral, non-facial melanomas from our hospital with linear shiny white structures. The outcome variable was the type of linear shiny white structures: shiny white streaks and white strands. We evaluated their association with explanatory variables that may affect the reflectance of melanomas and Breslow index. We used χ² statistics and also calculated the sensitivity and specificity of each linear shiny white structure to predict those variables. We detected linear shiny white structures in 118 melanomas. Regarding shiny white streaks, we only found a statistically significant positive relationship with fibrosis in the papillary dermis. Regarding white strands, we found statistically significant and positive relationships with hyperkeratosis, Breslow index of 0.8 mm or more and acanthosis. Sensitivity and specificity study revealed that the presence of shiny white streaks was the most sensitive (81.7%) and specific (72.3%) for fibrosis in the papillary dermis, and presence of white strands was the most sensitive (91.1%) and specific (85.7%) for hyperkeratosis.

A retrospective cohort study of the diagnostic value of different subtypes of atypical pigment network on dermoscopy

BACKGROUND

Atypical network encompasses several patterns. Few studies assess the sensitivity, specificity, and positive and negative predictive values of network subtypes.

OBJECTIVE

We assessed the diagnostic value of atypical network subtypes and their histopathologic correlates in cutaneous melanocytic lesions.

METHODS

A retrospective search (2014-2018) from a high-risk melanoma clinic for cases scored for atypical network with accompanying dermoscopic photographs yielded 120 lesions (15 melanoma; 30 severely, 38 moderately, and 32 mildly atypical nevi; 4 compound nevi; and 1 junctional nevus). A dermatopathologist blinded to diagnosis assessed dermoscopic and histologic features. Network abnormality correlates with histopathology and clinical diagnoses were assessed with sensitivity, specificity, positive and negative predictive values, and odds ratios.

RESULTS

A multivariable model with shiny white streaks (odds ratio 3.02) and inverse network (OR 4.46) was most predictive of melanoma or severe atypia. Positive predictive value for melanoma or severe atypia in decreasing order was inverse network (73.9%), shiny white streaks (71.4%), loss of network (46%), branched streaks (29.4%), and thick brown lines (28.4%).

LIMITATIONS

Cases were retrospectively found from a pigmented lesion clinic and evaluated by a single dermatopathologist.

CONCLUSION

Shiny white streaks and inverse network are most predictive of melanoma or severe atypia and warrant biopsy if found on dermoscopy.

Dermoscopy: A Review of the Structures That Facilitate Melanoma Detection

Melanoma is currently the fifth most common cancer in the United States, resulting in more than 9000 deaths each year. Despite numerous improvements in the management of advanced melanoma, the cornerstone to ensuring a cure remains early detection. Both patient and physician awareness regarding the signs and symptoms of early melanoma remain paramount. As a result, much effort has been and continues to be expended in developing and refining effective diagnostic algorithms to help identify melanomas and differentiate them from nevi, such as the ABCDE rule (A for asymmetry, B for border irregularity, C for color variegation, D for diameter >6 mm, and E for evolution in lesion size, shape, or color). To assist in the detection of more subtle melanomas requires technology to augment a visual examination. Toward this end, a simple instrument called a dermatoscope has transformed not only the appreciation of the morphology of melanoma but also its growth dynamics. The discipline of dermoscopy has improved the detection of melanoma and other skin cancers, has resulted in the detection of thinner melanomas, and has helped improve the ability to differentiate nevi (benign lesions) from melanomas, which, in turn, has resulted in fewer biopsies of benign lesions. Since patients often first present to their primary care physicians for their health-related concerns, it is imperative that primary care physicians be able to recognize the lesions that are suspicious for melanoma. This review is intended to introduce osteopathic physicians to the dermoscopic features associated primarily with melanomas located on nonglabrous skin.

Dermoscopic features of basal cell carcinoma and its subtypes: A systematic review

BACKGROUND

Multiple studies have reported on dermoscopic structures in basal cell carcinoma (BCC) and its subtypes, with varying results.

OBJECTIVE

To systematically review the prevalence of dermoscopic structures in BCC and its subtypes.

METHODS

Databases and reference lists were searched for relevant trials according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were assessed for the relative proportion of BCC dermoscopic features. Random-effects models were used to estimate summary effect sizes.

RESULTS

Included were 31 studies consisting of 5950 BCCs. The most common dermoscopic features seen in BCC were arborizing vessels (59%), shiny white structures (49%), and large blue-grey ovoid nests (34%). Arborizing vessels, ulceration, and blue-grey ovoid nests and globules were most common in nodular BCC; short-fine telangiectasia, multiple small erosions, and leaf-like, spoke wheel and concentric structures in superficial BCC; porcelain white areas and arborizing vessels in morpheaform BCC; and arborizing vessels and ulceration in infiltrative BCC.

LIMITATIONS

Studies had significant heterogeneity. Studies reporting BCC histopathologic subtypes did not provide clinical data on pigmentation of lesions.

CONCLUSION

In addition to arborizing vessels, shiny white structures are a common feature of BCC. A constellation of dermoscopic features may aid in differentiating between BCC histopathologic subtypes.

Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma

BACKGROUND

Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used.

OBJECTIVES

Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity.

MAIN RESULTS

We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT.

AUTHORS' CONCLUSIONS

Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.

Accuracy of tele-consultation on management decisions of lesions suspect for melanoma using reflectance confocal microscopy as a stand-alone diagnostic tool

BACKGROUND

Diagnostic accuracy of reflectance confocal microscopy (RCM) as a stand-alone diagnostic tool for suspect skin lesions has not been extensively studied.

OBJECTIVE

Primary aim was to measure experts' accuracy in RCM-based management decisions. Secondary aim was to identify melanoma-specific RCM features.

METHODS

The study enrolled patients ≥18 years that underwent biopsy of skin lesions clinically suspected to be melanoma. One hundred lesions imaged by RCM were randomly selected from 439 lesions prospectively collected at four pigmented lesion clinics. The study data set included 23 melanomas, three basal cell and two squamous cell carcinomas, 11 indeterminate melanocytic lesions and 61 benign lesions including 50 nevi. Three expert RCM evaluators were blinded to clinical or dermoscopic images, and to the final histopathological diagnosis. Evaluators independently issued a binary RCM-based management decision, 'biopsy' vs. 'observation'; these decisions were scored against histopathological diagnosis, with 'biopsy' as the correct management decision for malignant and indeterminate lesions. A subset analysis of 23 melanomas and 50 nevi with unequivocal histopathological diagnosis was performed to identify melanoma-specific RCM features.

RESULTS

Sensitivity, specificity and diagnostic accuracy were 74%, 67% and 70% for reader 1, 46%, 84% and 69% for reader 2, and 72%, 46% and 56% for reader 3, respectively. The overall kappa for management decisions was 0.34. Readers had unanimous agreement on management for 50 of the 100 lesions. Non-specific architecture, non-visible papillae, streaming of nuclei, coarse collagen fibres and abnormal vasculature showed a significant association with melanoma in the evaluation of at least two readers.

CONCLUSIONS

Reflectance confocal microscopy tele-consultation of especially challenging lesions, based on image review without benefit of clinical or dermoscopy images, may be associated with limited diagnostic accuracy and interobserver agreement. Architectural and stromal criteria may emerge as potentially useful and reproducible criteria for melanoma diagnosis.

Usefulness of dermoscopy to improve the clinical and histopathologic diagnosis of skin cancers

Multiple studies have shown that dermoscopy increases the sensitivity and specificity for the detection of skin cancers compared with examination by the naked eye. Dermoscopy can also lead to the detection of thinner and smaller cancers. In addition, dermoscopy leads to the more precise selection of lesions requiring excision. In essence, dermoscopy helps clinicians differentiate benign from malignant lesions through the presence or absence of specific dermoscopic structures. Therefore, because most dermoscopic structures have direct histopathologic correlates, dermoscopy can allow the prediction of certain histologic findings present in skin cancers, thus helping select management and treatment options for select types of skin cancers. Visualizing dermoscopic structures in the ex vivo specimens can also be beneficial. It can improve the histologic diagnostic accuracy by targeted step-sectioning in areas of concern, which can be marked by the clinician before sending the specimen to the pathologist, or by the pathologist on the excised specimen in the laboratory. In addition, ex vivo dermoscopy can also be used to select tumor areas with genetic importance because some dermoscopic structures have been related to mutations with theragnostic relevance. In the second article in this continuing medical education series, we review the impact of dermoscopy on the diagnostic accuracy of skin cancer, how dermoscopy can affect the histopathologic examination, and which dermoscopic features may be more relevant in terms of histologic and genetic prediction.

Dermoscopy pathology correlation in melanoma

Dermoscopy is a widely used technique whose role in the clinical (and preoperative) diagnosis of melanocytic and non-melanocytic skin lesions has been well established in recent years. The aim of this paper is to clarify the correlations between the "local" dermoscopic findings in melanoma and the underlying histology, in order to help clinicians in routine practice.

The diagnostic value and histologic correlate of distinct patterns of shiny white streaks for the diagnosis of melanoma: A retrospective, case-control study

BACKGROUND

Shiny white streaks (SWSs) are best visualized with polarized dermoscopy and correlate with dermal fibroplasia histopathologically. SWSs have been described at higher frequencies in melanomas than in benign nevi.

OBJECTIVE

We assessed the diagnostic value of different patterns of SWSs and their histologic correlate in melanocytic lesions.

METHODS

Polarized dermoscopic images of 1507 histopathologically diagnosed melanocytic neoplasms were analyzed for presence and pattern of SWSs. Histology was also reviewed for correlation.

RESULTS

Among 1507 melanocytic neoplasms, SWSs were observed in 31 of 144 melanomas (22%) and 22 of 1363 benign neoplasms (1.6%) (P < .001). The sensitivity and specificity of SWSs for melanoma were 22% and 98%, respectively. Diffuse SWSs exhibited the greatest diagnostic value for melanoma, with sensitivity of 11.8% and specificity of 99.5%. Focal central and peripheral SWSs were comparable in diagnostic significance. The presence of SWSs was highly uncommon in dysplastic nevi, whereas in certain benign subgroups of nevi such as Spitz nevi and atypical genital special site nevi, SWSs were not uncommon. Diffuse SWSs correlated with greater breadth of deep fibroplasia than focal SWSs (P = .009), and SWSs correlated with greater Breslow depth among melanomas (P = .007).

LIMITATIONS

This study was retrospective.

CONCLUSION

Polarized dermoscopy is a valuable diagnostic tool in the identification of SWSs, a feature that is highly specific for melanoma.

Enhancing Skin Cancer Diagnosis with Dermoscopy

Dermoscopy increases the sensitivity for skin cancer detection, decreases the number of benign lesions biopsied for each malignant diagnosis, and enables the diagnosis of thinner melanomas compared with naked eye examination. Multiple meta-analyses have identified that dermoscopy improves the diagnostic accuracy for melanoma when compared with naked eye examination. In addition, studies have established that dermoscopy can aid in the detection of keratinocyte carcinomas. Dermoscopy triage algorithms have been developed to help novices decide when a biopsy or a referral is most appropriate. In this article, the authors illustrate the dermoscopic features that assist in identifying melanoma and keratinocyte carcinomas.

Dermoscopic Clues for Diagnosing Melanomas That Resemble Seborrheic Keratosis

Importance

Melanomas that clinically mimic seborrheic keratosis (SK) can delay diagnosis and adequate treatment. However, little is known about the value of dermoscopy in recognizing these difficult-to-diagnose melanomas.

Objective

To describe the dermoscopic features of SK-like melanomas to understand their clinical morphology.

Design, Setting, and Participants

This observational retrospective study used 134 clinical and dermoscopic images of histopathologically proven melanomas in 134 patients treated in 9 skin cancer centers in Spain, France, Italy, and Austria. Without knowledge that the definite diagnosis for all the lesions was melanoma, 2 dermoscopy-trained observers evaluated the clinical descriptions and 48 dermoscopic features (including all melanocytic and nonmelanocytic criteria) of all 134 images and classified each dermoscopically as SK or not SK. The total dermoscopy score and the 7-point checklist score were assessed. Images of the lesions and patient data were collected from July 15, 2013, through July 31, 2014.

Main Outcomes and Measures

Frequencies of specific morphologic patterns of (clinically and dermoscopically) SK-like melanomas, patient demographics, and interobserver agreement of criteria were evaluated.

Results

Of the 134 cases collected from 72 men and 61 women, all of whom were white and who had a mean (SD) age of 55.6 (17.5) years, 110 (82.1%) revealed dermoscopic features suggestive of melanoma, including pigment network (74 [55.2%]), blue-white veil (72 [53.7%]), globules and dots (68 [50.7%]), pseudopods or streaks (47 [35.1%]), and blue-black sign (43 [32.3%]). The remaining 24 cases (17.9%) were considered likely SKs, even by dermoscopy. Overall, lesions showed a scaly and hyperkeratotic surface (45 [33.6%]), yellowish keratin (42 [31.3%]), comedo-like openings (41 [30.5%]), and milia-like cysts (30 [22.4%]). The entire sample achieved a mean (SD) total dermoscopy score of 4.7 (1.6) and a 7-point checklist score of 4.4 (2.3), while dermoscopically SK-like melanomas achieved a total dermoscopy score of only 4.2 (1.3) and a 7-point checklist score of 2.0 (1.9), both in the range of benignity. The most helpful criteria in correctly diagnosing SK-like melanomas were the presence of blue-white veil, pseudopods or streaks, and pigment network. Multivariate analysis found only the blue-black sign to be significantly associated with a correct diagnosis, while hyperkeratosis and fissures and ridges were independent risk markers of dermoscopically SK-like melanomas.

Conclusions and Relevance

Seborrheic keratosis-like melanomas can be dermoscopically challenging, but the presence of the blue-black sign, pigment network, pseudopods or streaks, and/or blue-white veil, despite the presence of other SK features, allows the correct diagnosis of most of the difficult melanoma cases.

Validity and Reliability of Dermoscopic Criteria Used to Differentiate Nevi From Melanoma: A Web-Based International Dermoscopy Society Study

IMPORTANCE

The comparative diagnostic performance of dermoscopic algorithms and their individual criteria are not well studied.

OBJECTIVES

To analyze the discriminatory power and reliability of dermoscopic criteria used in melanoma detection and compare the diagnostic accuracy of existing algorithms.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective, observational study of 477 lesions (119 melanomas [24.9%] and 358 nevi [75.1%]), which were divided into 12 image sets that consisted of 39 or 40 images per set. A link on the International Dermoscopy Society website from January 1, 2011, through December 31, 2011, directed participants to the study website. Data analysis was performed from June 1, 2013, through May 31, 2015. Participants included physicians, residents, and medical students, and there were no specialty-type or experience-level restrictions. Participants were randomly assigned to evaluate 1 of the 12 image sets.

MAIN OUTCOMES AND MEASURES

Associations with melanoma and intraclass correlation coefficients (ICCs) were evaluated for the presence of dermoscopic criteria. Diagnostic accuracy measures were estimated for the following algorithms: the ABCD rule, the Menzies method, the 7-point checklist, the 3-point checklist, chaos and clues, and CASH (color, architecture, symmetry, and homogeneity).

RESULTS

A total of 240 participants registered, and 103 (42.9%) evaluated all images. The 110 participants (45.8%) who evaluated fewer than 20 lesions were excluded, resulting in data from 130 participants (54.2%), 121 (93.1%) of whom were regular dermoscopy users. Criteria associated with melanoma included marked architectural disorder (odds ratio [OR], 6.6; 95% CI, 5.6-7.8), pattern asymmetry (OR, 4.9; 95% CI, 4.1-5.8), nonorganized pattern (OR, 3.3; 95% CI, 2.9-3.7), border score of 6 (OR, 3.3; 95% CI, 2.5-4.3), and contour asymmetry (OR, 3.2; 95% CI, 2.7-3.7) (P < .001 for all). Most dermoscopic criteria had poor to fair interobserver agreement. Criteria that reached moderate levels of agreement included comma vessels (ICC, 0.44; 95% CI, 0.40-0.49), absence of vessels (ICC, 0.46; 95% CI, 0.42-0.51), dark brown color (ICC, 0.40; 95% CI, 0.35-0.44), and architectural disorder (ICC, 0.43; 95% CI, 0.39-0.48). The Menzies method had the highest sensitivity for melanoma diagnosis (95.1%) but the lowest specificity (24.8%) compared with any other method (P < .001). The ABCD rule had the highest specificity (59.4%). All methods had similar areas under the receiver operating characteristic curves.

CONCLUSIONS AND RELEVANCE

Important dermoscopic criteria for melanoma recognition were revalidated by participants with varied experience. Six algorithms tested had similar but modest levels of diagnostic accuracy, and the interobserver agreement of most individual criteria was poor.

Triage amalgamated dermoscopic algorithm (TADA) for skin cancer screening

Importance

Dermoscopic triage algorithms have been shown to improve beginners’ abilities for identifying pigmented skin lesions requiring biopsy.

Objective

To estimate the diagnostic accuracy of the Triage Amalgamated Dermoscopic Algorithm (TADA) for pigmented and nonpigmented skin cancers. Secondarily, to compare TADAs performance to those of existing triage algorithms for the identification of pigmented skin cancers.

Design

Cross-sectional, observational, reader study that took place at a beginner and intermediate level dermoscopy course.

Participants

Two hundred medical professionals of various specialties attended the course and 120 voluntarily joined the study (60% participation rate).

Exposures

After receiving basic dermoscopy training, participants evaluated 50 polarized, dermoscopic images of pigmented (22 benign, 18 malignant) and nonpigmented (1 benign, 9 malignant) skin lesions using TADA. Pigmented lesions were also evaluated using the Three-Point Checklist and AC Rule. With TADA, participants first determined if a lesion was an unequivocal angioma, dermatofibroma, or seborrheic keratosis, which would exclude it from further evaluation. All other lesions were assessed for architectural disorder, starburst pattern, blue-black or gray color, shiny white structures, negative network, ulcer/erosion, or vessels. Any one feature indicated suspicion for malignancy.

Results

Most participants were dermatologists (n=64, 53.3%) or primary care physicians (n=41, 34.2%), and many lacked previous dermoscopy training (n=52, 43.3%). TADA’s sensitivity and specificity for all skin cancers was 94.6% (95% CI=93.4–95.7%) and 72.5% (95% CI=70.1–74.7%), respectively. For pigmented skin cancers, the sensitivity and specificity were 94.0% (95% CI=92.9–95.0%) and 75.5% (95% CI=73.8–77.2%). This compared to 71.9% (95%CI=69.8–73.9%) and 81.4% (95%CI=79.7–83.0%) for the Three-Point Checklist and 88.6% (95%CI=87.1–89.9%) and 78.7% (95%CI=76.9–80.3%) for the AC Rule.

Conclusions

These results suggest that TADA compares favorably to existing triage algorithms and might be a useful triage tool with high sensitivity and specificity for pigmented and nonpigmented skin cancers. Further studies are needed to validate these preliminary observations.

Association of Shiny White Blotches and Strands With Nonpigmented Basal Cell Carcinoma: Evaluation of an Additional Dermoscopic Diagnostic Criterion

IMPORTANCE

Basal cell carcinoma (BCC) is the most common type of skin cancer and is usually nonpigmented. Shiny white structures (SWSs) are frequently present in BCC.

OBJECTIVE

To determine the diagnostic accuracy of various morphologies of SWSs for diagnosis of nonpigmented BCC.

DESIGN, SETTING, AND PARTICIPANTS

Nonpigmented skin tumors, determined clinically and dermoscopically, were identified from a database of lesions consecutively biopsied over a 3-year period (January 2, 2009, to December 31, 2012) from a single dermatology practice. Data analysis was conducted from October 9, 2014, to November 15, 2015. Investigators blinded to histopathologic diagnosis evaluated the polarized dermoscopic images for the presence of SWSs, which were categorized as blotches, strands, short white lines, and rosettes. Measures of diagnostic accuracy for BCC were estimated. Participants included 2375 patients from a dermatologic clinic in Plantation, Florida. Review of the medical records identified 2891 biopsied skin lesions; 457 of these were nonpigmented neoplasms.

MAIN OUTCOMES AND MEASURES

Diagnosis of BCC with dermoscopy compared with all other diagnoses combined was the primary outcome; the secondary outcome was diagnosis of BCC compared with amelanotic melanoma. We calculated diagnostic accuracy measured as odds ratios (ORs), sensitivity, and specificity of shiny white blotches and/or strands for the diagnosis of BCC.

RESULTS

Of the 457 nonpigmented neoplasms evaluated, 287 (62.8%) were BCCs, 106 (23.2%) were squamous cell carcinoma, 39 (8.5%) were lichen planus-like keratosis, 21 (4.6%) were melanomas, and 4 (0.9%) were nevi. The prevalence of SWSs was 49.0% (n = 224). In multivariate analysis (reported as OR [95% CI]) controlling for age, sex, and anatomical location, the presence of any SWS was associated with a diagnosis of BCC (2.3 [1.5-3.6]; P < .001). Blotches (6.3 [3.6-10.9]; P < .001), strands (4.9 [2.9-8.4]; P < .001), and blotches and strands together (6.1 [3.3-11.3]; P < .001) were positively associated with BCC. Shiny white blotches and strands together had a diagnostic sensitivity of 30% and specificity of 91%.

CONCLUSIONS AND RELEVANCE

The combined presence of shiny white blotches and strands is associated with high diagnostic specificity for nonpigmented BCC.

A Clinical Aid for Detecting Skin Cancer: The Triage Amalgamated Dermoscopic Algorithm (TADA)

PURPOSE

Family physicians (FPs) frequently evaluate skin lesions but may not have the necessary training to accurately and confidently identify lesions that require skin biopsy or specialist referral. We evaluated the diagnostic performance of a new, simplified dermoscopy algorithm for skin cancer detection.

METHODS

In this cross-sectional, observation study, attendees of a dermoscopy course evaluated 50 polarized dermoscopy images of skin lesions (27 malignant and 23 benign) using the Triage Amalgamated Dermoscopic Algorithm (TADA). The dermoscopic criteria of TADA include architectural disorder (ie, disorganized or asymmetric distribution of colors and/or structures), starburst pattern, blue-black or gray color, white structures, negative network, ulcer, and vessels. The study occurred after 1 day of basic dermoscopy training. Clinical information related to palpation (ie, firm, dimpling) was provided when relevant.

RESULTS

Of 200 course attendees, 120 (60%) participated in the study. Participants included 64 (53.3%) dermatologists and 41 (34.2%) primary care physicians, 19 (46.3%) of whom were FPs. Fifty-two (43%) individuals had no previous dermoscopy training. Overall, the sensitivity and specificity of TADA for malignant skin lesions was 94.8% and 72.3%, respectively. Previous dermoscopy training and years of dermoscopy experience were not associated with diagnostic sensitivity (P = .13 and P = .05, respectively) or specificity (P = .36 and P = .21, respectively). Specialty type was not associated with sensitivity (P = .37) but dermatologists had a higher specificity than nondermatologists (79% v. 72%, P = .008).

CONCLUSIONS

After basic instruction, TADA may be a useful dermoscopy algorithm for FPs who examine skin lesions as it has a high sensitivity for detecting skin cancer.

First description of the dermatoscopic features of acquired elastotic hemangioma-a case report

We present a case of acquired elastotic hemangioma (AEH), a rare, benign vascular tumor. A Caucasian male in his 60s presented with an asymptomatic, solitary, non-pigmented and violaceous lesion of short duration on the dorsum of his hand. The lesion had unique clinical, dermatoscopic and pathological features. Dermatoscopic images of the lesion are presented for characterization and histopathological correlation that have not previously been published or described.

Dermoscopy of Melanomas on the Trunk and Extremities in Asians

The incidence of melanoma among the Asian population is lower compared to that among the Western European population. These populations differed in their most common histopathologic subtypes, acral lentiginous melanoma being the most common in the Asian population. Although the dermoscopic features of the melanomas on the acral skin have been thoroughly investigated in the Asian population, studies concerning the dermoscopic patterns of melanomas on the non-acral skin have been scarce. The aim of this study was to investigate the dermoscopic patterns of melanomas on the trunk and extremities in the Asian population. To achieve this, we evaluated the dermoscopic patterns of 22 primary melanomas diagnosed at two university hospitals in Korea. In addition, 100 benign melanocytic lesions were included as the control group for comparative analysis. A P value less than 0.05 was regarded as statistically significant. Melanoma-associated dermoscopic features such as asymmetry (odds ratio [OR], 30.00), multicolor pattern (OR, 30.12), blotches (OR, 13.50), blue white veils (OR, 15.75), atypical pigment networks (OR, 9.71), irregular peripheral streaks (OR, 6.30), atypical vascular patterns (OR, 11.50), ulcers (OR, 15.83), atypical dots/globules (OR, 3.15), shiny white lines (OR, 5.88), and regression structures (OR, 7.06) were more commonly observed in patients with melanomas than in patients of the control group. The mean dermoscopic scores obtained on the 7-point checklist, revised 7-point checklist, 3-point checklist, ABCD rule, and CASH algorithm were 5.36, 3.41, 2.05, 6.89, and 9.68, respectively, in the primary melanomas, and 1.33, 0.93, 0.46, 2.45, and 3.60, respectively, in the control group (all, P < 0.001). The present study showed that melanoma-related dermoscopic patterns were common in Asian patients. Dermoscopy is a reliable diagnostic tool for the melanomas of the trunk and extremities in the Asian populations.

A risk scoring system for the differentiation between melanoma with regression and regressing nevi

BACKGROUND

Spontaneous regression of melanomas is relatively common, its prevalence ranging from 10 to 35%. However, regressing nevi can exhibit worrisome feature and simulate melanoma both clinically and dermoscopically. Thus, the presence of regression can represent a confounding factor.

OBJECTIVE

To investigate the frequency of dermoscopic patterns of "regression" in a series of benign and malignant melanocytic skin lesions, and to design an integrated scoring system. Scoring classifiers are very effective in selecting the significant parameters for discriminating two clinical conditions, thus can rapidly calculate a patient's risk for a given disease.

METHODS

We selected a series of 95 regressing melanocytic lesions, including 50 regressing nevi and 45 melanomas with regression. For each lesion, 12 dermoscopic variables (i.e. five types of regression structures, five atypical pigmentation structures, atypical vascular pattern and pink areas) were examined by three expert in dermoscopy (blinded to the histological diagnosis). The dermoscopic evaluation was then combined with patient age, gender, body site and the maximum diameter of lesion. Concordance analysis with Cohen's kappa was performed between the three clinicians. A risk scoring system was designed by the leave-one-out cross-validation procedure to ensure model prediction power.

RESULTS

The predictive score model revealed a sensitivity of 97.8% and a specificity of 75.5% in discriminating nevi and melanomas with regression. Using the score model, the diagnostic performance of the examiners increased by an average of 23.7% in sensitivity and 5.9% in specificity, compared with standard dermoscopic pattern analysis.

CONCLUSIONS

We assessed the validity of an integrated risk scoring model as a new methodological approach that could help the dermatologist in the differentiation between melanoma with regression and regressing nevus. Future studies could test the setting up of a score model over an even more complex pool of data obtained from different skin lesions with various diagnostic devices.

Standardization of terminology in dermoscopy/dermatoscopy: Results of the third consensus conference of the International Society of Dermoscopy

BACKGROUND

Evolving dermoscopic terminology motivated us to initiate a new consensus.

OBJECTIVE

We sought to establish a dictionary of standardized terms.

METHODS

We reviewed the medical literature, conducted a survey, and convened a discussion among experts.

RESULTS

Two competitive terminologies exist, a more metaphoric terminology that includes numerous terms and a descriptive terminology based on 5 basic terms. In a survey among members of the International Society of Dermoscopy (IDS) 23.5% (n = 201) participants preferentially use descriptive terminology, 20.1% (n = 172) use metaphoric terminology, and 484 (56.5%) use both. More participants who had been initially trained by metaphoric terminology prefer using descriptive terminology than vice versa (9.7% vs 2.6%, P < .001). Most new terms that were published since the last consensus conference in 2003 were unknown to the majority of the participants. There was uniform consensus that both terminologies are suitable, that metaphoric terms need definitions, that synonyms should be avoided, and that the creation of new metaphoric terms should be discouraged. The expert panel proposed a dictionary of standardized terms taking account of metaphoric and descriptive terms.

LIMITATIONS

A consensus seeks a workable compromise but does not guarantee its implementation.

CONCLUSION

The new consensus provides a revised framework of standardized terms to enhance the consistent use of dermoscopic terminology.

"Tape dermatoscopy": constructing a low-cost dermatoscope using a mobile phone, immersion fluid and transparent adhesive tape

Importance:

Medical professionals and indeed the general public have an increasing interest in the acquisition of dermatoscopic images of suspect or ambiguous skin lesions. To this end, good dermatoscopic image quality and low costs are important considerations.

Observations:

Images of seven lesions (seborrheic keratosis, melanoma in-situ, blue and dermal nevus, basal cell carcinoma and two squamous cell carcinomas) were taken. A novel technique of “tape dermatoscopy” involved:

Using immersion fluid (i.e., water, olive oil, disinfectant spray) placed on the flat or slightly elevated lesion;

Covering the lesion with transparent adhesive tape with lateral tension;

Using ambient indoor or outdoor lighting for illumination (rather than flash photography);

Positioning a photographic device at an angle of approximately 45° from the side of the lesion to avoid light reflection;

Recording a focused image with a mobile phone or digital camera at a distance of approximately 25–30 cm from the lesion; and

Enlarging the image on the screen of the device.

Essential dermatoscopic features enabling a correct diagnosis were visible in 6 of the 7 lesions. ‘Tape dermatoscopy” images of the lesions were compared to standard dermatoscopy (using a Fotofinder handyscope® in combination with a mobile phone). The latter confirmed the dermatoscopic features in six of seven lesions.

Conclusions and Relevance:

“Tape dermatoscopy” images can be recorded by medical personnel and even the general public without a dermatoscope. However, the limitations of this method are that images may be unfocused, exophytic tumors may be difficult to assess, excess pressure on tumoral blood vessels may lead to compression artefact, dermatoscopic features that are only visible under polarized light are unable to be detected (particularly “crystalline” or “chrysalis” structures) and tumors in certain anatomic locations may be difficult to assess (e.g., edges of nose, ears [demonstrated in one case], nails). Comparative prospective studies are necessary in order to test reproducibility of these preliminary findings, to establish special indications for the technique, and to develop guidelines for its effective use.

Nodular melanoma: five consecutive cases in a general practice with polarized and non-polarized dermatoscopy and dermatopathology

Background:

The incidence of nodular melanoma (NM) has been consistently described as at least 10–15% of total melanomas for over 15 years despite advances in diagnostic algorithms and medical technology. NMs are strongly correlated with faster rates of growth and poorer prognosis and thus provide clinicians with a challenge for early recognition.

Objective:

To evaluate diagnostic clues of consecutive histopathologically proven NMs in one general practice with particular emphasis on dermatoscopic characteristics and compare this to the published literature.

Method:

A retrospective observational study was performed of five consecutive histologically proven NM, from a total of 212 consecutive melanomas from a general practice in Brisbane, Queensland, Australia. Dermatoscopic images, both polarized and non-polarized, which appears to be a unique resource, and dermatopathologic slides were available for all lesions.

Results:

All of the NMs in this series were pigmented although one was hypomelanotic. Two of them were symmetrical. The most highly sensitive clues to NM were gray or blue structures and polarizing-specific white lines.

Limitations:

Due to the small number of NMs in this report no statistical significance can be attributed to the observational findings.

Conclusion:

This small series supports what is already known: that a significant proportion of NMs may be dermatoscopically symmetrical but that known clues to melanoma are frequently present. Nodular lesions, pigmented or non-pigmented, should be excised to exclude NM if there is any clue to malignancy, regardless of symmetry, unless a confident specific benign diagnosis can be made.

Prediction without Pigment: a decision algorithm for non-pigmented skin malignancy

While there are several published comprehensive stepwise algorithmic methods for diagnosing pigmented skin malignancy, only limited material has been published for the stepwise assessment of non-pigmented lesions. We present a method based on pattern analysis, with a stepwise assessment, first, for ulceration, second, for white clues (defined as white lines, or in the case of a raised lesion any of the keratin clues: dermatoscopic white circles, dermatoscopic white structureless areas or surface keratin), and third, if no ulceration or white clues are present, proceed to vessel pattern analysis.

This is a novel method, and apart from the assessment of white clues in raised lesions, it has not been formally tested. The priority of keratin clues in raised lesions over vessel pattern analysis has, however, been verified.

It is conceded that this method is less specific than methods which have clues of pigmented structures, and accepting these limitations, Prediction without Pigment is a decision algorithm intended to guide the clinician in the decision as to whether to perform a biopsy rather than consistently leading to a specific diagnosis. Reaching a more specific diagnosis at the end of our flowchart can be achieved by weighing of clues both clinical and dermatoscopic, and that ability can be expected to improve with both knowledge and experience, but no diagnostic method, including this one, can be 100% sensitive in diagnosing malignancy, in particular, melanoma. Taking these limitations into account, any non-pigmented lesion, regardless of pattern analysis, which is raised and firm (nodular) and for which a confident, specific benign diagnosis cannot be made, should be excised to exclude the nodular variant of amelanotic melanoma.

Balloon cell melanoma: a case report with polarized and non-polarized dermatoscopy and dermatopathology

Balloon cell melanoma is a rare melanoma subtype, with only one previous case with dermatoscopy published. It is often non-pigmented, leading to diagnostic difficulty, and there is a tendency for lesions to be thick at diagnosis. We report a case of balloon cell melanoma on the forearm of a 61-year-old man with both polarized and non-polarized dermatoscopy and dermatopathology. It presented as a firm pale nodule with focal eccentric pigmentation. The clinical images evoke a differential diagnosis of dermatofibroma, dermal nevus, Spitz nevus and basal cell carcinoma as well as melanoma. This melanoma was partially pigmented due to a small, pigmented superficial spreading component on the edge of the non-pigmented balloon cell nodule, prompting further evaluation. In retrospect there was the clue to malignancy of polarizing-specific white lines (chrysalis structures) and polymorphous vessels, including a pattern of dot vessels. The reticular lines exclude basal cell carcinoma, polarizing-specific white lines are inconsistent with the diagnosis of dermal nevus and their eccentric location is inconsistent with both Spitz nevus and dermatofibroma. Excision biopsy was performed, revealing a superficial spreading melanoma with two distinct invasive components, one of atypical non-mature epithelioid cells and the other an amelanotic nodular component, comprising more than 50% of the lesion, characterized by markedly distended epithelioid melanocytes showing pseudo-xanthomatous cytoplasmic balloon cell morphology. A diagnosis of balloon cell melanoma, Breslow thickness 1.9 mm, mitotic rate 3 per square millimeter was rendered. Wide local excision was performed, as was sentinel lymph node biopsy, which was negative.

Dermoscopy for the pediatric dermatologist part III: dermoscopy of melanocytic lesions

Melanocytic nevi encompass a variety of lesions, including blue, Spitz, congenital, and acquired nevi. These nevi can occasionally manifest clinical morphologies resembling melanoma, and the presence of such nevi in children can elicit anxiety in patients, parents, and clinicians. Dermoscopy has been shown to increase the diagnostic accuracy for melanoma and to help differentiate melanoma from nevi, ultimately aiding in the decision-making process as to whether to perform a biopsy. Dermoscopy is the perfect instrument to use during the evaluation of pigmented skin lesions in children because it is painless and provides important information for the clinician that can assist in formulating appropriate management decisions. This review highlights the most common benign dermoscopic patterns encountered in nevi and discuss the 10 most common dermoscopic structures seen in melanomas. Lesions manifesting a benign dermoscopic pattern and lacking any melanoma-specific structures do not need to be excised and can safely be monitored. In contrast, melanomas will invariably deviate from the benign nevus patterns and will usually manifest at least 1 of the 10 melanoma-specific structures: atypical network, negative network, streaks, crystalline structures, atypical dots and globules, irregular blotch, blue-white veil, regression structures, peripheral brown structureless areas, and atypical vessels. It is important to be cognizant of the fact that melanomas in childhood usually do not manifest the clinical ABCD features. Instead, they are often symmetric, amelanotic, nodular lesions. Although the clinical appearance may not be alarming, with dermoscopy they will invariably manifest at least one melanoma-specific structure, the most common being atypical vascular structures and crystalline structures.