Quality assessment of a large primary GP skin cancer service in Auckland, New Zealand.

AIM: Waitemata District Health Board has implemented a new approach to the management of skin cancers by triaging lesions to specialist-trained general practitioners (GPSI) with the aim of reducing patient wait times and treatment costs. The primary outcome was to determine positive margin rates for the GP surgeons, with secondary outcome being infection rates. METHOD: A retrospective audit was conducted on all excisions (n=2,705) performed between 1 January 2016 and 31 December 2016 by the 13 WDHB GPSIs. Electronic patient records were accessed to review data. Each lesion was classified into benign, in-situ (pre-malignant) and malignant categories. Surgical margins were analysed for non-melanotic skin cancers (NMSC) and determined as positive, close or negative. Infection rates determined by microbiology results and prescribing information and time to treat analyses were conducted. RESULTS: WDHB GPSIs performed 2,705 excisions, 1,887 (69.8%) of which were malignant lesions. Among the 1,486 NMSC excised, a positive surgical margin was observed in 51 (3.4%). There were 294 (10.9%) cases of infection in 2,705 excisions. Median time to treat was 31 days across all lesions. New Zealand papers from the last two decades estimate the NMSC positive margin rate among primary care physicians varies between 16-31%; most recent papers have published rates 6.8-9.5%.European publications describe positive margin rates ranging between 13.9-33.5%. CONCLUSION: This study validates the use of surgically trained GP surgeons and shows their integral role in managing the high volume of skin cancer in New Zealand.

Skin cancer prevention campaign aimed at beachgoers on the Costa del Sol (southern Spain).

BACKGROUND: Sunbathing on the beach is one of the main risks for skin cancer. OBJECTIVE: In the summer of 2010, a skin cancer prevention campaign aimed at beachgoers was undertaken on the western Costa del Sol (southern Spain). METHODS: The campaign took place on beaches during July and August. A multicomponent intervention was conducted by a dermatologist and other healthcare professionals, including: (1) interviews about risk factors and sun protection habits; (2) full skin examination using dermoscopy; (3) health advice plus educational brochure; (4) sunscreen workshop plus free samples; and (5) survey about satisfaction and behavioral intentions. A journalism and health prize was offered to encourage mass media coverage. RESULTS: Four hundred and seven beachgoers (56% tourists) were recruited during the campaign, mean age 45 years. Most of the participants reported high-risk sun exposure and revealed high rates of clinically suspicious lesions of skin cancer (8.1%), melanoma (2.9%), actinic keratosis (10.2%), and atypical nevus (7.6%). The campaign was highly appreciated by the participants and followed not only by local but also regional and national media. CONCLUSION: Beachgoers are a strategic target to prevent skin cancer. Beaches are also suitable places to develop a skin cancer prevention campaign, allowing direct access to the high-risk population for surveying, health behavior education, and screening. Several keys may be useful to optimize results as the design of a personalized intervention of proven efficacy, provision of a trained healthcare team, and development of an attractive strategy for the mass media.

Fluorescence in-situ hybridization and dermoscopy in the assessment of controversial melanocytic tumors.

Although the 'gold standard' for melanoma diagnosis remains histopathological analysis, presently dermoscopists play a significant role in the diagnostic process. However, even a combined approach may not allow a clear-cut judgment on equivocal melanocytic lesions. Fluorescence in-situ hybridization (FISH) can offer assistance in the evaluation of chromosome abnormalities associated with malignancies, and its role is emerging in melanoma diagnosis. The aim of this study was to evaluate the diagnostic role of the FISH in the assessment of controversial lesions, defined as those lesions showing discrepancies between dermatoscopic and histological evaluations. Twenty clinically and histologically ambiguous melanocytic lesions were selected. After the first histopathologic diagnosis, a second pathologist examined the specimens in a blinded review for a second opinion and to identify the most suitable areas to hybridize using probes specific to RREB1, MYB, and CCND1 genes and the centromere of chromosome 6. The first histopathological evaluation led to the diagnosis of melanoma in seven cases, whereas the second identified eight cases of malignant melanoma and was in agreement with the first in 65% of cases and with dermoscopy in 40% of cases. Cytogenetic abnormalities detected by FISH are markers of malignancy that can be useful in the characterization of difficult-to-diagnose melanocytic tumors, when the dermatologist and the pathologist have a different opinions.

Expression of soluble adenylyl cyclase in lentigo maligna: use of immunohistochemistry with anti-soluble adenylyl cyclase antibody (R21) in diagnosis of lentigo maligna and assessment of margins.

CONTEXT: Soluble adenylyl cyclase (sAC) is an enzyme that generates cyclic adenosine monophosphate, a signaling molecule involved in regulating melanocyte functions. R21, a mouse monoclonal antibody against sAC, shows a striking pan-nuclear staining in lentigo maligna, indicating possible utility for diagnosis and margin assessment. OBJECTIVE: To evaluate R21 in the diagnosis and evaluation of margins in lentigo maligna. DESIGN: Thirty one re-excision specimens for lentigo maligna were evaluated for R21 expression using previously published protocol. In addition, 153 cases including 41 lentigo malignas, 30 non-lentigo maligna-type melanomas, 38 lentigos, and 44 nevi were evaluated using a modified stringent protocol to eliminate all nonmelanocyte staining. RESULTS: The sensitivity of nuclear staining with R21 in lentigo maligna was 87.8%. Nuclear expression of sAC was observed in 40% of other melanomas and 2.3% of benign nevi. R21 did not stain nuclei of resting melanocytes but was observed in 28.9% of melanocytic hyperplasias. These cases were easily distinguished from lentigo maligna in routine sections. R21 staining facilitated extent of the lesion in resection margins. In cases examined under the less stringent conditions, interpretation was facilitated by comparing R21 and Mart1/Melan A staining. Greater than 9 pan-nuclear staining melanocytes within one high-power field along with a pan-nuclear sAC/Melan A ratio greater than 0.5 was consistent with a positive margin whereas 5 or less pan-nuclear staining melanocytes along with a sAC/Melan A ratio of less than 0.3 constituted a negative margin. CONCLUSION: R21 is a useful diagnostic adjunct in the diagnosis and evaluation of margins in re-excision specimens in lentigo maligna.

Correlation between histologic assessment and fluorescence in situ hybridization using MelanoSITE in evaluation of histologically ambiguous melanocytic lesions.

CONTEXT: The 4-probe, multicolor, fluorescence in situ hybridization (FISH) panel targeting chromosomes 6 and 11 has shown promising sensitivity and specificity in distinguishing between benign nevi and malignant melanoma. Only a few studies have assessed the potential utility of FISH in classification of histologically ambiguous melanocytic lesions. In the United States, this assay is exclusively licensed to NeoGenomics Laboratories (Irvine, California), which provides the technical component and has developed an innovative service (MelanoSITE) allowing pathologists to interpret FISH results using a dedicated Web portal. Thus far, use of MelanoSITE as a diagnostic adjunct in the diagnosis of melanocytic lesions has not, to our knowledge, been reported in the literature. OBJECTIVE: To analyze 1.5 years of experience with the MelanoSITE melanoma FISH assay in the evaluation of histologically ambiguous lesions in the context of second opinion and routine dermatopathology practice. DESIGN: A prospective histologic/FISH correlation study of 140 cases. RESULTS: Twenty-seven percent of abnormal FISH results were false-positive results because of tetraploidy. After correcting for known false-positive results, all lesions considered atypical nevi showed normal FISH signals. Abnormal FISH signals were reported in 30% of lesions considered histologically borderline and in 48% of lesions in which a diagnosis of melanoma was favored. CONCLUSIONS: Four-probe, multicolor FISH results for melanoma correlate with the microscopic assessments of histologically ambiguous lesions. Pathologists using MelanoSITE must be aware of the high rate of false-positive results from tetraploidy.

Automated skin lesion assessment using mobile technologies and cloud platforms.

This paper presents a smart phone based system for storing digital images of skin areas depicting regions of interest (lesions) and performing self-assessment of these skin lesions within these areas. The system consists of a mobile application that can acquire and identify moles in skin images and classify them according their severity into melanoma, nevus and benign lesions. The proposed system includes also a cloud infrastructure exploiting computational and storage resources. This cloud-based architecture provides interoperability and support of various mobile environments as well as flexibility in enhancing the classification model. Initial evaluation results are quite promising and indicate that the application can be used for the task of skin lesions initial assessment.

The usefulness of c-Kit in the immunohistochemical assessment of melanocytic lesions.

C-Kit (CD117), the receptor for the stem cell factor, a growth factor for melanocyte migration and proliferation, has shown differential immunostaining in various benign and malignant melanocytic lesions. The purpose of this study is to compare c-Kit immunostaining in benign nevi and in primary and metastatic malignant melanomas, to determine whether c-Kit can aid in the differential diagnosis of these lesions. c-Kit immunostaining was performed in 60 cases of pigmented lesions, including 39 benign nevi (5 blue nevi, 5 intradermal nevi, 3 junctional nevi, 15 cases of primary compound nevus, 11 cases of Spitz nevus), 18 cases of primary malignant melanoma and 3 cases of metastatic melanoma. The vast majority of nevi and melanomas examined in this study were positive for c-Kit, with minimal differences between benign and malignant lesions. C-Kit cytoplasmatic immunoreactivity in the intraepidermal proliferating nevus cells, was detected in benign pigmented lesions as well as in malignant melanoma, increasing with the age of patients (P=0.007) in both groups. The patient's age at presentation appeared to be the variable able to cluster benign and malignant pigmented lesions. The percentage of c-Kit positive intraepidermal nevus cells was better associated with age despite other variables (P=0.014). The intensity and percentage of c-Kit positivity in the proliferating nevus cells in the dermis was significantly increased in malignant melanocytic lesions (P=0.015 and P=0.008) compared to benign lesions (compound melanocytic nevi, Spitz nevi, intradermal nevi, blue nevi). Immunostaning for c-Kit in metastatic melanomas was negative. Interestingly in two cases of melanoma occurring on a pre-existent nevus, the melanoma tumor cells showed strong cytoplasmatic and membranous positivity for c-kit, in contrast with the absence of any immunoreactivity in pre-existent intradermal nevus cells. C-Kit does not appear to be a strong immunohistochemical marker for distinguishing melanoma from melanocytic nevi, if we consider c-Kit expression in intraepidermal proliferating cells. The c-Kit expression in proliferating melanocytes in the dermis could help in the differential diagnosis between a superficial spreading melanoma (with dermis invasion) and a compound nevus or an intradermal nevus. Finally, c-Kit could be a good diagnostic tool for distinguishing benign compound nevi from malignant melanocytic lesions with dermis invasion and to differentiate metastatic melanoma from primary melanoma.

The remote assessment of melanocytic skin lesions: a viable alternative to face-to-face consultation.

BACKGROUND: The incidence of melanoma continues to rise in the Western world, prompting health care professionals to search for novel tools that may increase rates of early detection. Here we focus on one such tool: remote specialist diagnosis of melanocytic lesions utilising mobile-phone camera patient-generated clinical images. OBJECTIVE: We aim to test the hypothesis that patient-generated clinical images utilising mobile phones are of acceptable quality, and that digital image diagnostic outcomes are comparable with face-to-face (FTF) diagnostic outcomes. METHODS: Study participants were asked to photograph, using their mobile-phone camera any number of their own melanocytic naevi, and then upload these clinical images to a central server. Diagnostic accuracy of the management decision based on assessing these digital images was tested by comparing results from digital image assessment with results from FTF assessments. RESULTS: We provide evidence that suggests potential patients are capable of uploading good quality clinical images of melanocytic lesions for diagnostic purposes, and we show that good concordance rates can be achieved with respect to digital image and FTF diagnostic outcomes. With respect to the latter, exact agreement was found in 116 of 167 assessable lesions (69%). CONCLUSIONS: This work suggests that specialist remote diagnosis of patient-generated clinical images of melanocytic lesions utilising mobile-phone cameras may be a viable alternative to traditional FTF assessments.

Clinical pathway for melanoma detection using comprehensive cutaneous analysis with Melanoscan.

The usefulness of a comprehensive cutaneous photography system (Melanoscan) was tested using the following parameters: 1) decision to screen pathway, 2) clinical pathway, 3) clinical outcome, and 4) patient acceptance. The results indicate that 55 percent of those with criteria for scanning were reimbursed by insurance (AMA CTP category 1 code status 96904 for total body photography). In this model of whole body scanning, the ratio of time demand on physicians, patients, and technicians is 1:8:12. In 53 patients, 394 lesions of concern were identified. Of these lesions, 48 (12.31%) were scars, 306 (78.46%) were changed, and 36 (9.23%) were new. The decision to biopsy was made for 18 of the 394 lesions analyzed in the follow-up studies. Sensitivity of the process in determining malignant lesions is 75.00 percent and specificity is 73.70 percent. Preliminary results suggest that change detection analysis reduces the number of biopsies and improves diagnostic accuracy. Assessment of survey results revealed a high degree of patient satisfaction with ease of following Melanoscan directions (81.25%), as well as overall satisfaction with the process (73.44%). These results suggest that whole body screening using the Melanoscan provides a device in which accuracy of lesion tracking, patient confidence in lesion documentation, and clinician time are optimized.

Malignant melanoma detection by Bag-of-Features classification.

In this paper, we apply a Bag-of-Features approach to malignant melanoma detection based on epiluminescence microscopy imaging. Each skin lesion is represented by a histogram of codewords or clusters identified from a training data set. Classification results using Naive Bayes classification and Support Vector Machines are reported. The best performance obtained is 82.21% on a dataset of 100 skin lesion images. Furthermore, since in melanoma screening false negative errors have a much higher impact and associated cost than false positive ones, we use the Neyman-Pearson score in our model selection scheme.

Preoperative ultrasonic assessment of thin melanocytic skin lesions using a 100-MHz ultrasound transducer: a comparative study.

BACKGROUND: It has been shown that tumor thickness (TT) of melanocytic skin lesions (MSL) of less than 1 mm vertical thickness assessed by 20 MHz are often incorrectly evaluated. OBJECTIVE: We aimed to evaluate the accuracy of 100-MHz ultrasound for the determination of TT of thin MSL, compared with conventional 20-MHz ultrasound and histologic findings. METHODS: Thirty-seven patients with 50 suspicious MSL, including tumor diameter up to 1 cm and maximum vertical TT of less than 1 mm, were recruited. The agreement between the histologically and ultrasographically measured TT was analyzed using Bland and Altman plots. RESULTS: Compared to histology, 20-MHz ultrasound (33.9 microm) as well as 100-MHz (16 microm) resulted in overestimation of TT that was twofold higher for 20-MHz ultrasound. The latter also revealed wider 95% limits of agreement (4.9 to 63 microm) than 100-MHz ultrasound (3.5 to 28.7 microm). CONCLUSION: Analysis of agreement clearly demonstrated that the performance of 100-MHz ultrasound is superior to conventional 20-MHz ultrasound, even though a relatively small positive bias was observed in 100-MHz ultrasound, indicating a systematic error. We consider 100-MHz ultrasound a useful tool for the noninvasive determination of TT of thin MSL in vivo.

Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data.

OBJECTIVE: To describe the workload profile in a network of Australian skin cancer clinics. DESIGN AND SETTING: Analysis of billing data for the first 6 months of 2005 in a primary-care skin cancer clinic network, consisting of seven clinics and staffed by 20 doctors, located in the Northern Territory, Queensland and New South Wales. MAIN OUTCOME MEASURES: Consultation to biopsy ratio (CBR); biopsy to treatment ratio (BTR); number of benign naevi excised per melanoma (number needed to treat [NNT]). RESULTS: Of 69 780 billed activities, 34 622 (49.6%) were consultations, 19 358 (27.7%) biopsies, 8055 (11.5%) surgical excisions, 2804 (4.0%) additional surgical repairs, 1613 (2.3%) non-surgical treatments of cancers and 3328 (4.8%) treatments of premalignant or non-malignant lesions. A total of 6438 cancers were treated (116 melanomas by excision, 4709 non-melanoma skin cancers [NMSCs] by excision, and 1613 NMSCs non-surgically); 5251 (65.2%) surgical wounds were repaired by direct suture, 2651 (32.9%) by a flap (of which 44.8% were simple flaps), 42 (0.5%) by wedge excision and 111 (1.4%) by grafts. The CBR was 1.79, the BTR was 3.1 and the NNT was 28.6. CONCLUSIONS: In this network of Australian skin cancer clinics, one in three biopsies identified a skin cancer (BTR, 3.1), and about 29 benign lesions were excised per melanoma (NNT, 28.6). The estimated NNT was similar to that reported previously in general practice. More data are needed on health outcomes, including effectiveness of treatment and surgical repair.

Monte Carlo simulation of light-tissue interaction: three-dimensional simulation for trans-illumination-based imaging of skin lesions.

Three-dimensional, voxel-based, and wavelength-dependent skin lesion models are developed and simulated using Monte Carlo techniques. The optical geometry of the Nevoscope with trans-illumination is used in the simulations for characterizing the lesion thickness. Based on the correlation analysis between the lesion thickness and the diffuse reflectance, optical wavelengths are selected for multispectral imaging of skin lesions using the Nevoscope. Tissue optical properties reported by various researchers are compiled together to form a voxel library. Tissue models used in the simulations are developed using the voxel library which offers flexibility in updating the optical properties and adding new media types into the models independent of the Monte Carlo simulation code.

Consent to medical treatment.

Obtaining patient consent is good medical practice and a legal necessity. This article examines the duty of general practitioners to obtain consent from patients for medical interventions and outlines the process of obtaining consent.

Colors in atypical nevi: a computer description reproducing clinical assessment.

BACKGROUND/PURPOSE: Atypical nevi (AN) share some dermoscopic features with early melanoma (MM), and computer elaboration of digital images could represent a useful support to diagnosis to assess automatically colors in AN, and to compare the data with those referring to clearly benign nevi (BN) and MMs. METHODS: An image analysis program enabling the numerical description of color areas in melanocytic lesions was used on 459 videomicroscopic images, referring to 76 AN, 288 clearly BN and 95 MMs. RESULTS: Black, white and blue-gray were more frequently found in AN than in clearly BN, but less frequently than in MMs. Color area values significantly differed between the three groups. CONCLUSION: The clinical-morphological interpretation of the numerical data, based on the mathematical description of the aspect and distribution of different color areas in different lesion types may contribute to the characterization of AN and their distinction from MMs.

In vivo assessment of melanocytic nests in nevi and melanomas by reflectance confocal microscopy.

In vivo reflectance confocal microscopy is a novel technique for the noninvasive study and diagnosis of the skin. The aim of this study was to describe and characterize the cytological and architectural aspects of cell clusters in melanocytic lesions observed by confocal microscopy, and to correlate them with routine histopathology. A total of 55 melanocytic lesions comprising 20 melanomas, 25 acquired nevi and 10 Spitz nevi were studied by means of reflectance confocal microscopy, dermoscopy and routine histopathology. Three different types of cell clusters at confocal microscopy observation (dense, sparse cell and cerebriform clusters) were identified and correlated with histopathology. Dense clusters appeared characteristic for benign lesions, although present in 13 out of 20 melanomas. Sparse cell clusters were more frequently observable in melanomas, but also sporadically present in one Spitz nevus. Moreover, cerebriform clusters were exclusively observed in five out of 20 melanomas. Confocal microscopy allowed the in vivo characterization of aspects of melanocytic nests and their exact correlation with histopathology.

The development of an improved method of photography for mole-monitoring at the University Hospital of North Durham.

The past decade has witnessed a dramatic increase in the number of patients presenting with pigmented lesions to general practitioners. This increase is reflected in the number of patients referred for whole body mole-monitoring photographs to the Medical Photography and Illustration Department of the University Hospital of North Durham. Through a process of qualitative and quantitative research, an improved method of whole body photographic mole-monitoring was devised and implemented within this department. All aspects of the mole-monitoring service were evaluated, from the original photographic request to the photographic session and patient interaction. This process also offered the opportunity to explore the possible use of new technologies.