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1.
Exp Dermatol ; 2020 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-32748489

RESUMO

BACKGROUND: In-vivo reflectance confocal microscopy (RCM) increases diagnostic accuracy for melanoma diagnosis when combined with dermoscopy. In patients with multiple atypical nevi a comparative dermoscopic approach improves melanoma recognition and saves unnecessary excision. The performance of a comparative approach combining dermoscopy and RCM has not been yet investigated. OBJECTIVE: To validate a comparative dermoscopic+RCM approach according to melanoma diagnostic accuracy in patients with multiple atypical nevi. METHODS: Consecutive patients undergoing RCM examination for ≥ 3 atypical melanocytic lesions, assessed with a dermoscopic+RCM comparative approach in a real-life setting, from July 2012 to April 2018 at a single center, were enrolled. Dermoscopic and dermoscopic+RCM morphologic approaches were retrospectively applied by evaluating revisited 7-point check list, RCM and Delphi scores for each enrolled lesion. Comparative dermoscopic and dermoscopic+RCM approaches were subsequently used. For each approach, lesions were classified as non-suspicious (long-term follow-up) or suspicious (short-term follow-up or excision) and diagnostic accuracy for melanoma diagnosis was assessed. RESULTS: Diagnostic accuracy progressively increased comparing morphologic to comparative approaches, and comparing dermoscopic to dermoscopic+RCM approaches. The retrospective comparative dermoscopic+RCM approach revealed the largest area under the curve (0.84; 95%CI:0.79-0.89; p<0.001) and the lowest number needed to excise (5.7). Furthermore, this approach had the highest specificity (67.6%) and sensitivity (100%) levels, which were similar to those verified in the real-life setting. The main study limitations are the retrospective design and high risk patient inclusion only. CONCLUSIONS: Comparative dermoscopic+RCM approach increases melanoma diagnostic accuracy, reducing unnecessary excision without missing melanomas.

4.
Int J Dermatol ; 2020 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-32726478

RESUMO

BACKGROUND: Amelanotic and hypomelanotic melanoma (AHM) has a higher risk of delayed diagnosis and a significant lower 5-year melanoma-specific survival compared to pigmented melanoma. Our aim was the evaluation of the clinicopathological/dermoscopic features of amelanotic melanoma (AM) and hypomelanotic melanoma (HM). METHODS: All participants had a personal history of AHM. We defined HM as showing clinical/dermoscopic pigmentation in < 25% of the lesion's surface and histopathological focal pigmentation, while AM as melanomas with clinical/dermoscopic and histopathological absence of pigmentation. RESULTS: The most common phenotypic traits among the 145 AHM patients were as follows: phototype II, blue-grey eyes, and dark brown hair. Red hair was present in 23.8% AHM cases (AM = 22.60%; HM = 25.80%). The most affected area was the back (29.5%). A total of 67.1% were classified as AM and 32.9% as HM. The most represented hair colors in AM and HM were, respectively, blonde and dark brown hair. Median Breslow thickness was 1.7 mm, superficial spreading melanoma (SSM) and nodular melanoma (NM) were the most represented histotypes, and mitotic rate > 1 × mm2 was reported in 73.3% cases, and regression was significantly more present in HM. Dermoscopy showed high prevalence of white structureless zones (63.4%), linear looped vessels (58.8%), linear irregular vessels (50.0%), and arborizing vessels (47.2%). Multivariate logistic regression confirmed the association between the presence of pigmentation and the following: histological regression, dermoscopic globules, and arborizing vessels. CONCLUSIONS: Predominance of red hair in AHM patients was not confirmed. AHM affects mostly intermittent sun-exposed body areas. The deeper median Breslow thickness (versus pigmented melanoma), the association of AM with the nodular histotype, and the high mitotic rate highlight the AHM's aggressiveness. HM's higher levels of regression can be explained by the presence of pigmentation, driving the underlying immune response. AHM showed a polymorphous vascular pattern and significant presence of arborizing vessels (especially HM).

5.
J Am Acad Dermatol ; 2020 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-32730850

RESUMO

BACKGROUND: There is lack of studies on the diagnostic accuracy of dermatoscopy and reflectance confocal microscopy (RCM) for dark pigmented lesions. OBJECTIVE: To assess the diagnostic accuracy of dermatoscopy plus confocal microscopy for melanoma diagnosis of dark pigmented lesions in real life. METHODS: Prospective analysis of difficult dark lesions with clinical-dermatoscopic suspicion of melanoma referred to RCM for further analysis. Outcome of lesions could be: excision or dermatoscopic digital follow up. RESULTS: We included 370 clinically dark lesions from 350 patients (median age, 45 years). Due to the clinical-dermatoscopic-RCM approach, we saved 129/213 unnecessary biopsies (specificity of 60.6%) with a sensitivity of 98.1% (154/157). Number needed to excise with the addition of RCM was 1.5 for melanoma diagnosis. LIMITATIONS: Single institution based; Italian population only. CONCLUSIONS: This study demonstrated that RCM coupled with dermatoscopy increase the specificity for diagnosing melanoma and it helps to correctly identify benign lesions. Our findings provide the basis for subsequent prospective studies on melanocytic neoplasms belonging to patients in different countries.

6.
J Am Acad Dermatol ; 2020 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-32534083

RESUMO

BACKGROUND: Nevus phenotype is a marker of melanoma risk. In-vivo prediction of microscopic pattern is needed to more precisely classify nevi. OBJECTIVE: To identify dermoscopic and clinical predictors of microscopic patterns of typical nevi. METHODS: We used reflectance confocal microscopy (RCM) to classify microscopic patterns of nevi. We prospectively accrued adults presenting for periodic-skin-screening and imaged, with dermoscopy and RCM, three randomly-selected nevi - from upper and lower back and lower extremity. RCM patterns were classified into Ring, Clod, Meshwork, and Composite. Logistic-regression was used to identify best predictors of RCM pattern. RESULTS: The study included 310 nevi from 112 participants (mean age=44; 51 females). Dermoscopic-reticular pattern correlated most frequently (59.9%) with RCM-Ring pattern, dermoscopic-globular with RCM-Composite (56.6%) and RCM-Clod (35.9%), dermoscopic-complex with RCM-Composite (76.3%), and dermoscopic-homogenous with RCM-Clod (50.8%). Integrating dermoscopic pattern with contour, diameter, color and anatomic location of nevi, improved prediction of microscopic patterns beyond dermoscopy alone. The dermoscopic-clinical regression-model correctly classified lesions to RCM-Ring vs. RCM-Clod in 90%, and to RCM-Ring vs. RCM-Composite patterns in 81%. LIMITATIONS: The study was restricted to adults, back and lower extremities and typical nevi. CONCLUSIONS: Integrating dermoscopic patterns with clinical attributes may improve prediction of microscopic patterns of nevi.

7.
Nat Med ; 2020 Jun 22.
Artigo em Inglês | MEDLINE | ID: mdl-32572267

RESUMO

The rapid increase in telemedicine coupled with recent advances in diagnostic artificial intelligence (AI) create the imperative to consider the opportunities and risks of inserting AI-based support into new paradigms of care. Here we build on recent achievements in the accuracy of image-based AI for skin cancer diagnosis to address the effects of varied representations of AI-based support across different levels of clinical expertise and multiple clinical workflows. We find that good quality AI-based support of clinical decision-making improves diagnostic accuracy over that of either AI or physicians alone, and that the least experienced clinicians gain the most from AI-based support. We further find that AI-based multiclass probabilities outperformed content-based image retrieval (CBIR) representations of AI in the mobile technology environment, and AI-based support had utility in simulations of second opinions and of telemedicine triage. In addition to demonstrating the potential benefits associated with good quality AI in the hands of non-expert clinicians, we find that faulty AI can mislead the entire spectrum of clinicians, including experts. Lastly, we show that insights derived from AI class-activation maps can inform improvements in human diagnosis. Together, our approach and findings offer a framework for future studies across the spectrum of image-based diagnostics to improve human-computer collaboration in clinical practice.

8.
J Am Acad Dermatol ; 2020 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-32592885

RESUMO

BACKGROUND: A recently introduced dermatoscopic method for diagnosis of early lentigo maligna (LM) is based on the absence of prevalent patterns of pigmented actinic keratosis (PAK) and solar lentigo/flat seborrheic keratosis (SL/SK). We term this the "inverse approach" OBJECTIVE: To determine whether training on the inverse approach increases the diagnostic accuracy of readers as compared to classic pattern analysis. METHODS: We used clinical and dermatoscopic images of histopathologically diagnosed LMs, PAKs and SLs/SKs. Participants of a dermatoscopy masterclass classified the lesions at baseline, after training on pattern analysis and the inverse approach. We compared their diagnostic performance among the 3 time points and to that of a trained convolutional neural network (CNN). RESULTS: The mean sensitivity for LM without training was 51.5%, after training on pattern analysis increased to 56.7% and after learning the inverse approach to 83.6%. The mean proportion of correct answers at the 3 time points was 62.1%, 65.5% and 78.5%. The percentage of readers outperforming the CNN was 6.4%, 15.4% and 53.9%, respectively. LIMITATIONS: The experimental setting and the inclusion of histopathologically diagnosed lesions only. CONCLUSIONS: The inverse approach, added to the classic pattern analysis, significantly improves the sensitivity of human readers for early LM diagnosis.

9.
Dermatol Ther ; : e13744, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32478958

RESUMO

Recently, 5-fluorouracil 0.5%/salicylic acid 10% (5-FU/SA) topical solution has been included in the National Italian portfolio for lesion-directed treatment of grade I/II actinic keratosis (AKs) located on the face or scalp. To describe the utility of dermoscopy and RCM in treatment response monitoring of a series of AKs treated with 5-FU/SA as lesion-directed therapy. Consecutive patients were prospectively treated for a maximum of 12 weeks with 5-FU/SA for AKs located on the face or scalp. Clinical, dermoscopic, and confocal images of one index AK were acquired at each visit and pre-specified criteria were evaluated. Clinical, dermoscopic, and confocal responses were evaluated at last follow-up visit. Fourteen patients were enrolled, of which five were treated for 12 weeks, seven for 8, and two for 4 weeks. At a median follow up of 30 weeks, 64.3% (9/14) index AKs achieved complete clinical, 50% (7/14) complete dermoscopic and 42.9% (6/14) complete confocal clearance. Local skin reaction was mild and significantly decreased during therapy administration. Although the small number of cases, our study underlines the utility of both dermoscopy and in-vivo RCM in 5-FU/SA treatment response monitoring for AKs located on the face or scalp.

10.
J Am Acad Dermatol ; 2020 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-32454102

RESUMO

BACKGROUND: There is lack of uniformity in the reflectance confocal microscopy (RCM) terminology for melanocytic lesions. OBJECTIVE: To review published RCM terms for melanocytic lesions and identify redundant, synonymous terms. METHODS: A systematic review of original research articles adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted until August 15, 2018. Two investigators gathered all published RCM terms used to describe melanoma and melanocytic nevi. Synonymous terms were grouped based on similarity in definition and in histopathologic correlation. RESULTS: Out of 156 full-text screened articles, 59 studies met the inclusion criteria. We identified 209 terms; 191 (91.4%) corresponding to high-magnification/cellular-level terms and 18 (8.6%) corresponding to low-magnification/architectural patterns terms. The overall average use frequency of RCM terms was 3.1 times (range, 1-31). By grouping of individual RCM terms based on likely synonymous definitions and by eliminating terms lacking clear definition, the total number of RCM terms could be potentially reduced from 209 to 40 terms (80.8% reduction). LIMITATIONS: Non-English and non-peer-reviewed articles were excluded. CONCLUSIONS: This systematic review of published RCM terms identified significant terminology redundancy. It provides the basis for subsequent terminology consensus on melanocytic neoplasms.

11.
Int J Dermatol ; 59(7): 813-821, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32406113

RESUMO

BACKGROUND: Nevus-associated melanoma (NAM) has been regarded as a distinct biological entity from de-novo melanoma (DNM); however, static dermoscopy often fails in differentiating these entities. Digital dermoscopic monitoring allows to identify dynamic changes occurring during follow-up; this may improve diagnostic accuracy and potentially our knowledge on NAM biology. We aimed to define main independent factors associated with NAM diagnosis and those influencing follow-up time in a population of melanomas excised at follow-up. METHODS: A cohort of melanomas excised at follow-up was retrospectively and consecutively selected. NAMs and DNMs were compared according to baseline features and main dermoscopic changes occurring during follow-up. Univariate and multivariable logistic and Cox's regression analysis were performed to respectively define factors associated with NAM diagnosis and those influencing the risk for excision. RESULTS: Eighty-six melanomas were enrolled, of which 21 (24.4%) were nevus-associated. During follow-up NAMs mainly underwent atypical network modifications (47.6%), followed by inverse network (28.6%) and dermoscopic island (23.8%) worsening or appearance. DNMs were also mainly characterized by atypical network modifications (47.7%), however, a significant proportion of cases underwent irregular pigmentation/dots/globules or regression changes (29.2%), which were rarely seen among NAMs. Furthermore, both multivariable logistic and Cox's regression analysis demonstrated a significant association between NAM and a longer follow-up. CONCLUSIONS: We demonstrated that among melanomas excised at follow-up, different patterns of dermoscopic changes may be found between NAMs and DNMs. This finding, together with the association of NAM with a longer follow-up time, supports the hypothesis of different biological behavior of these two entities.

13.
J Am Acad Dermatol ; 2020 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-32360715

RESUMO

BACKGROUND: No specific features of nevus-associated melanoma (NAM) are currently defined. OBJECTIVE: To identify clinical/dermoscopic features of NAM. METHODS: Retrospective evaluation of histopathologically diagnosed NAM. RESULTS: 80/165 NAMs had a clinically recognizable nevus component, often raised or nodular, most frequently characterized by different morphologic clones and/or colors. In 111/165 NAMs, dermoscopy revealed a nevus component, prevalently characterized by regular dots/clods and structureless brown areas. Clinically, the melanoma component was eccentric/peripheral in 45/80 cases, central in 35/80; dermoscopically, the figures were 59/111 and 52/111, respectively. Melanomas associated with congenital nevi (C-NAMs) occur at younger age and have a thicker Breslow than melanomas associated with acquired nevi (NC-NAMs). Dermoscopically regular dots/globules characterize C-NAMs, hypopigmented structureless areas characterize NC-NAMs. LIMITATIONS: Retrospective analysis. CONCLUSION: C-NAMs are oftener central to congenital nevus, with clod/globular or structureless brown pattern, typical of young patients. NC-NAMs are frequently hypopigmented nodules/plaques, eccentric/peripheral, with hypopigmented structureless areas, typical of elders.

14.
Sci Rep ; 10(1): 6337, 2020 Apr 14.
Artigo em Inglês | MEDLINE | ID: mdl-32286422

RESUMO

The present paper provides a multidisciplinary fine-scale description of a Mediterranean mesophotic new habitat dominated by the bivalve Neopycnodonte cochlear (Poli, 1795), building large and thick pinnacles on vertical cliffs at two study areas along the southern Italian coast. The pinnacles, constituted by a multilayered aggregation of living and dead specimens of N. cochlear, were interconnected with each other to form a framework of high structural complexity, never observed before for this species. The bioconstruction, considerably extended, resulted very complex and diversified in the associated community of structuring organisms. This latter included 165 taxa attributable to different ecological groups occurring in different microhabitats of the bioconstruction. Among the secondary structuring taxa there were scleractinians, serpulids and bryozoans, all contributing to the deposition of calcium carbonate, and poriferans, helping to bind shells together or eroding carbonate by boring species. In comparison with coralligenous sensu stricto and the recently described Mediterranean mesophotic coral reef, the Neopycnodonte bioconstruction showed peculiar features, since it lacked the major contribution of encrusting coralline algae and scleractinians as reef builders, respectively.

16.
J Clin Oncol ; 38(14): 1591-1601, 2020 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-32167862

RESUMO

PURPOSE: Thin melanomas (T1; ≤ 1 mm) constitute 70% of newly diagnosed cutaneous melanomas. Regional node metastasis determined by sentinel node biopsy (SNB) is an important prognostic factor for T1 melanoma. However, current melanoma guidelines do not provide clear indications on when to perform SNB in T1 disease and stress an individualized approach to SNB that considers all clinicopathologic risk factors. We aimed to identify determinants of sentinel node (SN) status for incorporation into an externally validated nomogram to better select patients with T1 disease for SNB. PATIENTS AND METHODS: The development cohort comprised 3,666 patients with T1 disease consecutively treated at the Istituto Nazionale Tumori (Milan, Italy) between 2001 and 2018; 4,227 patients with T1 disease treated at 13 other European centers over the same period formed the validation cohort. A random forest procedure was applied to the development data set to select characteristics associated with SN status for inclusion in a multiple binary logistic model from which a nomogram was elaborated. Decision curve analyses assessed the clinical utility of the nomogram. RESULTS: Of patients in the development cohort, 1,635 underwent SNB; 108 patients (6.6%) were SN positive. By univariable analysis, age, growth phase, Breslow thickness, ulceration, mitotic rate, regression, and lymphovascular invasion were significantly associated with SN status. The random forest procedure selected 6 variables (not growth phase) for inclusion in the logistic model and nomogram. The nomogram proved well calibrated and had good discriminative ability in both cohorts. Decision curve analyses revealed the superior net benefit of the nomogram compared with each individual variable included in it as well as with variables suggested by current guidelines. CONCLUSION: We propose the nomogram as a decision aid in all patients with T1 melanoma being considered for SNB.

18.
JAMA Dermatol ; 2020 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-32101255

RESUMO

Importance: The clinical and dermoscopic features of the vast majority of uncommon variants of cutaneous melanoma have been rarely reported, leading to difficulty in making accurate diagnoses. Objective: To define the main clinical and dermoscopic features of the most frequently reported but uncommon histologic variants of cutaneous melanoma. Evidence Review: A 2-step systematic review of the literature was performed (from inception to November 2018) using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The first step identified those uncommon variants of melanoma for which at least 1 case reporting dermoscopy was described in the literature. The keywords searched were melanoma, uncommon, rare, dermoscopy, and dermatoscopy. In the second step, each previously identified uncommon variant was searched for in the same databases by combining the following terms with melanoma, dermoscopy, and dermatoscopy: amelanotic, hypopigmented, animal, melanocytoma, balloon, desmoplastic, follicular, nested, nevoid, dermal, spitz*, spindle, and verrucous. The institution's database was also searched from January 2012 to September 2019 for histopathologically confirmed cases of the same melanoma variants. Each reviewer also assessed the quality of reporting in the included articles based on previously described guidelines. Findings: In total, 62 articles met the inclusion criteria, reporting 433 melanoma cases. An additional 56 cases of uncommon melanoma variants were retrieved from the institution's database for a total of 489 cases: 283 cases of amelanotic superficial spreading melanoma, 18 cases of animal-type and pigmented epithelioid melanocytoma, 7 cases of balloon cell melanoma, 71 cases of desmoplastic melanoma, 3 cases of follicular melanoma, 10 cases of nested melanoma, 33 cases of nevoid melanoma, 2 cases of primary dermal melanoma, 57 cases of spitzoid melanoma, and 5 cases of verrucous melanoma. These variants of melanoma occurred more frequently in women than men (147 cases vs 132 cases). Clinically, these tumors were mainly palpable (162 of 217 [74.7%]) or amelanotic (283 of 489 [57.9%]) lesions that could resemble other benign or malignant skin conditions; dermoscopy typically revealed a homogeneous pinkish background, white structures, and polymorphic vessels. The mean age of all included was 58 years (range, 1-89 years). Conclusions and Relevance: Uncommon melanoma variants may resemble both inflammatory disorders and other cutaneous neoplasms, representing a diagnostic pitfall even for the most experienced dermatologist. The purpose of this systematic review was to provide an extensive and detailed overview of specific clinical and dermoscopic features of each uncommon melanoma variant, highlighting the main criteria for differentiating these variants from other benign or malignant skin lesions.

19.
G Ital Dermatol Venereol ; 155(1): 65-75, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32100974

RESUMO

Nevus-associated melanoma (NAM) is defined on histopathological basis by the coexistence of melanoma and nevus components. Melanomas developing on pre-existing congenital or acquired nevi are usually of the superficial spreading subtype and harbor the BRAFV600E mutation. NAM accounts for almost one-third of melanoma cases As compared to de novo melanoma, NAM develops on younger patients, is more frequently located on the trunk, and is associated with a high nevus count, light eye color and history of frequent sunburns. NAM has been regarded as a model to investigate melanoma origin. Molecular analysis defining the mutation profile of NAM's nevus and melanoma components supported the existence of two pathways of melanoma development, the first not involving clinically visible precursors, the second involving melanocytic nevi as precursors. Concerning diagnosis, dermatoscopy may identify nevus and melanoma components when located side-by-side, but no specific criteria have been described when superimposed. In-vivo reflectance confocal microscopy significantly enhances the recognition of NAM by allowing the detection of nevus remnants when superficially located. Regarding prognosis, NAM is generally thinner and more frequently in-situ than de-novo melanoma. Furthermore, studies reporting survival analysis demonstrated a trend towards better overall, distant-metastasis-free and recurrence-free survival. Although a clinical, phenotypic and molecular profile of NAM has been defined, controversies still exist. In the current review, we widely report and discuss facts and controversies on NAM.

20.
Dermatology ; 236(3): 241-247, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31707398

RESUMO

BACKGROUND: The head and neck are considered one single anatomical unit. No data on clinical, dermoscopic and confocal aspects of neck melanoma are currently available. OBJECTIVES: To identify clinical, dermoscopic and confocal diagnostic features of neck melanomas. METHODS: Consecutive malignant (cases) and benign (controls) melanocytic skin lesions located on the neck, excised as suspected of being melanoma from March 2011 to February 2018, were retrospectively retrieved. Dermoscopic criteria of the 7-point checklist, integrated by other melanoma features (such as grey colour and irregular hyperpigmented areas) were assessed. Reflectance confocal microscopy (RCM) images were examined when available. RESULTS: 282 lesions located to the head and neck area were biopsied to rule out melanoma. Thirty-one out of 282 (11%) lesions were located on the neck: 21 melanomas and 10 naevi. Melanoma patients were older than patients with naevi (mean age: 60.4 vs. 37.9 years, p < 0.001). Neck melanomas were more frequently located on sun-damaged skin compared to naevi (76.2 vs. 30%, p = 0.02). Dermoscopically, neck melanomas were characterized by irregular dots/globules, grey colour and regression (76.2, 81 and 46.7% of cases) and showed criteria of lentigo maligna melanoma (LMM) in 52.4% of cases. Regression, grey colour, irregular hyperpigmented areas and criteria of LMM typified melanomas on sun-damaged skin, whereas tumours located on non-sun-damaged areas were often characterized by irregular pigmentation (blotches). RCM, implemented to dermoscopy, correctly diagnosed 10/12 melanomas and 3/5 naevi. CONCLUSION: Neck melanoma has peculiar clinical and dermoscopic aspects that could help clinicians to distinguish it from naevi and to diagnose melanoma earlier.

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