Accuracy and confidence in the clinical diagnosis of basal cell cancer using dermoscopy and reflex confocal microscopy.

BACKGROUND: Diagnosis of suspected basal cell carcinoma (BCC) is typically confirmed with incisional biopsy before referral to final surgery. OBJECTIVE: To investigate the clinical confidence and accuracy of physicians making a diagnosis of BCC based on dermoscopic and reflectance confocal microscopy (RCM) features. METHODS: This study was designed as a simulation to determine the certainty and willingness to refer to surgery without previous biopsy confirmation of BCC. Study subjects were identified with suspected BCC. Dermoscopic and RCM lesion images were obtained before biopsy. Eight clinicians with various expertise levels blindly interpreted these images and chose among four hypothetical treatment options: definite BCC, refer directly to surgery without biopsy; other malignancy, perform biopsy for diagnosis; uncertain diagnosis, perform biopsy; benign, do not biopsy. Decisions for treatment were based on dermoscopic images alone and, subsequently, on dermoscopic and RCM images combined. RESULTS: The sensitivity for referral to surgery without biopsy was 67.6% with the use of dermoscopy; the positive predictive value (PPV) was 97.0%. Adding RCM increased the sensitivity to 76.5% and the PPV to 98.6%. CONCLUSIONS: Dermoscopy provides a high PPV for BCC. The addition of RCM to dermoscopy increases diagnostic sensitivity, particularly in less experienced dermoscopists. Physician behavior might be different if actual referrals were made for surgery without biopsy.

Skin cancer prevention in annual performance of total skin examination, photoprotection counseling, and patient instruction of self-skin examination.

BACKGROUND: Prevention of skin cancer includes early diagnosis and photoprotection, such as by physician-performed total skin examination (TSE) and patient-performed self-skin examination (SSE). Hypothesizing that 90% of our patients receive an annual TSE, photoprotection counseling, and SSE instruction, we assessed the extent to which this was documented in patients' records. We also sought to identify differences in documentation of TSE, photoprotection counseling, and instruction on SSE with or without use of a dictation template prompting documentation. MATERIALS AND METHODS: Retrospective review of a random sample of 400 patients in an outpatient dermatology practice of a tertiary care academic medical center for any dermatology appointment between May 1 and July 31, 2007. Exclusion criteria included refusal to undergo TSE, lack of access to skin (e.g., wheelchair-bound or in cast), or inappropriate visit type (e.g., for acne, psoriasis, or lupus). RESULTS: Of 400 randomly selected patients, 313 met inclusion criteria. The dictation template was used in 133; of these, 89% (119/133) had documentation in their clinical note of a TSE (exclusive of the buttocks or groin area), and 98% (130/133) had documentation of instruction on sun protection and SSE. Without use of the dictation template, these percentages dropped to 78% (140/180) and 20% (36/180), respectively. Physicians using a dictation template were more likely to document having conducted a TSE and instructed patients on photoprotection and SSE. CONCLUSIONS: A dictation template aids documentation of annual TSE and patient education efforts on photoprotection and SSE.

The impact of biopsy technique on upstaging, residual disease, and outcome in cutaneous melanoma.

BACKGROUND: After skin biopsy of malignant melanoma, the findings in the subsequent wide local excision (WLE) sometimes result in upgrading of the T-category. Herein, we examine the influence of biopsy technique on residual disease in melanoma WLE specimens and on upstaging. METHODS: We performed a retrospective review of data from malignant melanoma patients who underwent sentinel lymph node biopsy between 1997 and 2010. RESULTS: A total of 609 patients were biopsied by shave (51%), punch (19%), and excision (30%). Residual disease was seen in 240 patients (39%) at WLE, of whom 60% had undergone shave biopsy. Fifty-nine patients had a T-category upgrade after WLE (10% of all patients); 64% were sampled by shave. Seven percent of patients with a T-category upgrade had negative margins initially. Positive biopsy margin and greater thickness predicted T-category upgrade. CONCLUSIONS: Partial biopsy for melanoma resulted in more residual disease at WLE and a higher rate of T-category upgrade. Moreover, the presence of negative margins at biopsy did not ensure lack of residual disease.

Risk factors associated with local and in-transit recurrence of cutaneous melanoma.

BACKGROUND: Understanding the risk factors for local and in-transit recurrences (LR/ITR) may help facilitate methods of prevention, early detection, and treatment. METHODS: A retrospective review of a prospectively collected database was performed on patients diagnosed with single-lesion cutaneous melanoma. Clinical and pathologic characteristics of the tumors were evaluated. RESULTS: Of 225 patients, 10% had LR/ITR. Patients with LR/ITR were older (P = .0002), had thicker tumors (P = .018), and positive angiolymphatic invasion more frequently (P < .0001). An increased tumor mitotic rate (TMR) was more common in LR/ITRs (P = .051). On univariate logistic regression, age, thickness, TMR of 11/mm(2) or greater, and angiolymphatic invasion were all significant risk factors for LR/ITR. Multivariate logistic regression showed age, thickness, and angiolymphatic invasion were the only significant risk factors. CONCLUSIONS: Older patients with thicker tumors and angiolymphatic invasion appear to be at higher risk for LR/ITR. Such patients warrant consideration of preventative strategies and should receive close clinical follow-up evaluation for early recurrence.

Optical transfer diagnosis of pigmented lesions.

BACKGROUND: Optical transfer diagnosis is a novel melanoma detection system that uses morphologic-physiologic mapping. OBJECTIVE: To further evaluate the potential of optical transfer diagnosis for distinguishing benign from malignant pigmented melanocytic neoplasms. METHODS AND MATERIALS: Ninety-four patients with pigmented lesions suggestive of melanoma were referred for optical transfer diagnosis. After lesions were scanned with the camera, they were removed for histopathologic examination by two dermatopathologists each. From the recorded images, morphologic-physiologic maps were created with prediction models of light absorption and scattering by chromophores such as hemoglobin, keratin, and melanin at different epidermal and dermal depths. Entropy and relative entropy values derived from the morphologic-physiologic maps and a set of pure morphologic parameters were analyzed for output prediction of melanoma versus nonmelanoma. Dermoscopic images were reviewed and scored using the color, architecture, symmetry, and homogeneity (CASH) algorithm to assign a value of clinical atypia. RESULTS Of the 118 scanned and biopsied lesions (median CASH score 8), 11 were identified as melanoma or atypical melanocytic hyperplasia consistent with melanoma. For identification of melanomas, optical transfer diagnosis had a sensitivity of 100% and a specificity of 90%. CONCLUSIONS: This technology continues to be a promising adjunct to clinical skin cancer screening.

Factors leading to the biopsy of 1547 pigmented lesions at Mayo Clinic, Scottsdale, Arizona, in 2005.

BACKGROUND: Both physician-driven and patient-driven factors influence biopsy decisions. We sought to determine the ratio of benign to malignant melanocytic biopsy findings in our general dermatology practice and to characterize the reasons for biopsy. METHODS: A retrospective review of institutional records (1 January to 31 December 2005) was undertaken. RESULTS: We identified 1398 nevi, 147 invasive and in situ melanomas, and two lesions interpreted as atypical melanocytic proliferations. Prior histories of melanoma, atypical nevi, or nonmelanoma skin cancer were common. Patient concerns about changes or symptoms drove about one-third of the biopsies. Physician concerns more commonly drove biopsies in men and older patients (> 60 years). Physician-directed biopsies more commonly yielded atypical nevi, but there was no difference in the likelihood of melanoma. The ratio of removed nevi to melanomas was 9.2 : 1. CONCLUSIONS: Both patient-driven and physician-driven indications lead to skin biopsies. We found no standard method of documentation of dermoscopic evaluation, which prevented us from making definitive conclusions about the role of dermoscopy in this cohort.

Optical transfer diagnosis of pigmented lesions: a pilot study.

OBJECTIVE: To evaluate the potential of a novel imaging technology, optical transfer diagnosis (OTD), for differentiation of benign from malignant pigmented melanocytic lesions. DESIGN: Patients with pigmented lesions suspicious for melanoma were referred for OTD. After scanning, lesions were biopsied for histopathologic examination, each by two separate dermatopathologists. To create morphologic-physiologic maps, the imaging system used the morphologic and physiologic parameters derived from prediction models of light absorption and scattering by chromophores such as hemoglobin, keratin, and melanin at different epidermal and dermal depths. The relative entropies were analyzed for output prediction of malignancy vs. nonmalignancy. SETTING: General dermatology clinic in a tertiary care academic medical center. PATIENTS: Fifty patients with suspected melanoma. INTERVENTION: OTD of pigmented lesions suspicious for melanoma, followed by biopsies for histopathologic examination. MAIN OUTCOME MEASURES: Histopathologic confirmation of malignant lesions identified by OTD as melanoma. RESULTS: Sixty-three pigmented suspicious lesions were scanned before being biopsied for histopathologic examination by the two dermatopathologists. Of the 63 lesions, five were identified as melanoma and 58 were found to be benign (including three seborrheic keratoses and 55 melanocytic nevi). OTD was able to identify the malignant lesions with 100% sensitivity and 94.8-96.6% specificity. CONCLUSIONS: Further study is indicated, but this technology is a promising adjunct to clinical skin cancer screening. Additionally, if the physiologic prediction models can be validated, OTD may facilitate the noninvasive study of some aspects of cutaneous physiology.

Malignant melanoma in the 21st century: the emerging molecular landscape.

Malignant melanoma presents a substantial clinical challenge. Current diagnostic methods are limited in their ability to diagnose early disease and accurately predict individual risk of disease progression and outcome. The lack of adequate approaches to properly define disease subgroups precludes rational treatment design and selection. Better tools are urgently needed to provide more accurate and personalized melanoma patient management. Recent progress in the understanding of the molecular aberrations that underlie melanoma oncogenesis will likely advance the diagnosis, prognosis, and treatment of melanoma. The emerging pattern of molecular complexity in melanoma tumors mirrors the clinical diversity of the disease and highlights the notion that melanoma, like other cancers, is not a single disease but a heterogeneous group of disorders that arise from complex molecular changes. Understanding of molecular aberrations involving important cellular processes, such as cellular signaling networks, cell cycle regulation, and cell death, will be essential for better diagnosis, accurate assessment of prognosis, and rational design of effective therapeutics. Defining an individual patient's unique tumor characteristics may lead to personalized prediction of outcomes and selection of therapy. We review the emerging molecular landscape of melanoma and its implications for better management of patients with melanoma.

Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment.

Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.

Malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis.

Malignant melanoma is an aggressive, therapy-resistant malignancy of melanocytes. The incidence of melanoma has been steadily increasing worldwide, resulting in an increasing public health problem. Exposure to solar UV radiation, fair skin, dysplastic nevi syndrome, and a family history of melanoma are major risk factors for melanoma development. The interactions between genetic and environmental risk factors that promote melanomagenesis are currently the subject of ongoing research. Avoidance of UV radiation and surveillance of high-risk patients have the potential to reduce the population burden of melanoma. Biopsies of the primary tumor and sampling of draining lymph nodes are required for optimal diagnosis and staging. Several clinically relevant pathologic subtypes have been identified and need to be recognized. Therapy for early disease is predominantly surgical, with a minor benefit noted with the use of adjuvant therapy. Management of systemic melanoma is a challenge because of a paucity of active treatment modalities. In the first part of this 2-part review, we discuss epidemiology, risk factors, screening, prevention, and diagnosis of malignant melanoma. Part 2 (which will appear in the April 2007 issue) will review melanoma staging, prognosis, and treatment.

The exanthem of acute pulmonary coccidioidomycosis: Clinical and histopathologic features of 3 cases and review of the literature.

BACKGROUND: Coccidioidomycosis may be associated with a reactive generalized cutaneous eruption early in the course of the illness. Detailed descriptions in the literature are scarce. OBSERVATIONS: We describe 3 patients with a florid eruption associated with pulmonary coccidioidomycosis. The exanthem mimicked erythema multiforme clinically but not histologically. In 2 of the patients, the eruption began before the presence of detectable antibodies in the serum. CONCLUSION: The presence of the exanthem, in combination with fever and/or pneumonia, was a helpful clue to the diagnosis of coccidioidomycosis.

An unusual case of calciphylaxis.

BACKGROUND: Cutaneous calciphylaxis is a rare disorder that occurs most frequently in patients with end-stage renal disease (ESRD), those on hemodialysis, and renal transplant recipients. It is frequently associated with hyperparathyroidism and a markedly elevated calcium-phosphate product, and it carries a high mortality rate. The usual clinical presentation is of painful, stellate necrosis of the thighs or buttocks, often in the setting of livedo reticularis. Death usually results from septicemia. OBJECTIVE: This report documents an unusual case of recurrent, self-limiting calciphylaxis in the setting of a patient with ESRD and discusses the clinical and pathologic features of this potentially very fatal disorder. METHODS AND RESULTS: A 52-year-old woman presented with a greater than one-year history of relapsing and remitting, exquisitely painful, necrotic, numular plaques on the abdomen, breast, and arm. This patient had a markedly elevated calcium-phosphate product and parathyroid hormone level. The diagnosis of calciphylaxis was made by wedge biopsy of the most recent plaque, revealing calcification of medium-sized subcutaneous vessels and lobular capillaries with associated epidermal necrosis. CONCLUSIONS: This case demonstrates an unusual clinical variant of calciphylaxis that presented without the characteristic stellate necrosis or livedo reticularis that normally marks this condition and spontaneous resolution without incurring septicemia. Regardless of morphology, calciphylaxis should be considered in the differential diagnosis of painful, necrotic lesions occurring in the setting of ESRD.