Dermoscopy and reflectance confocal microscopy of solitary flat pink lesions: A new combined score to diagnose amelanotic melanoma.

BACKGROUND: Differential diagnosis of amelanotic/hypomelanotic melanoma among solitary flat pink lesions is challenging, due to limited clinical and dermoscopic clues. Dermoscopy and reflectance confocal microscopy assessments improve diagnostic accuracy, but their combined capacity among solitary flat pink lesions is yet to be defined. OBJECTIVES: To determine (i) whether diagnostic accuracy is improved with combined dermoscopy and reflectance confocal microscopy, (ii) a model to estimate probability of flat amelanotic/hypomelanotic melanoma among solitary flat pink lesions. METHODS: A retrospective single-centre study of solitary flat pink lesions, excised for suspected malignancy between 2011 and 2022 was performed. Images were independently evaluated by two dermatologists, blinded to histopathological diagnosis. Diagnostic performance was evaluated on the receiver operating characteristic curve and the area under the curve. Predictive features were identified by univariate and multivariate logistic regression analyses. A final predictive nomogram of independent risk factors was calculated by backward likelihood ratio. Hypothesis being tested was formulated before data collection. RESULTS: A total of 184 patients (87 females, 47.3%) were included; mean age was 57.6 years (19-95). Combined dermoscopy and reflectance confocal microscopy was more sensitive (83%, CI 69.2-92.4 and 91.5%, CI 79.6-97.6) than dermoscopy alone (76.6%, CI 62.0-87.7 and 85.1%, CI 71.7-93.8). Predictive features defined the new model, including linear irregular vessels (4.26-folds, CI 1.5-12.1), peripheral pigment network (6.07-folds, CI 1.83-20.15), remnants of pigmentation (4.3-folds, CI 1.27-14.55) at dermoscopy and atypical honeycomb (9.98-folds, CI 1.91-51.96), disarranged epidermal pattern (15.22-folds, CI 2.18-106.23), dendritic pagetoid cells in the epidermis (3.77-folds, CI 1.25-11.26), hypopigmented pagetoid cells (27.05-folds, CI 1.57-465.5), and dense and sparse nests (3.68-folds, CI 1.24-10.96) in reflectance confocal microscopy. Diagnostic accuracy of the model was high (AUC 0.91). CONCLUSIONS: Adjunctive reflectance confocal microscopy increases diagnostic sensitivity of flat amelanotic/hypomelanotic melanoma differential diagnosis. The proposed model requires validation.

Evaluation of chest pain in patients with low to intermediate pretest probability of coronary artery disease by electron beam computed tomography.

Despite its limited sensitivity and specificity in patients with low to intermediate probability of coronary artery disease (CAD), exercise treadmill testing (ETT) is frequently used as the initial test for investigation of chest pain. Although myocardial perfusion imaging is a significantly more accurate test, its added cost to ETT is considerable. The cost of a non-contrast electron beam computed tomography (EBCT) scan is comparable to that of ETT and the calcium score (CS) correlates closely with the volume of atherosclerotic plaque. Therefore, we tested the hypothesis that EBCT might be an effective and cost-beneficial technique for the identification of angiographically obstructive CAD (> or = 50% stenosis) in patients with low to intermediate pretest probability of disease. We calculated the theoretic cost of attaining a diagnosis of CAD based on a Bayesian model that utilizes published sensitivity and specificity levels for ETT, EBCT, and stress myocardial perfusion imaging. We then submitted a cohort of 207 patients with low to intermediate probability of disease both to EBCT and ETT in random order, and estimated the cost of achieving a correct diagnosis by either route based on the number of expected further tests. An EBCT calcium score of 150 was chosen as a cut-point with a sensitivity of 74% and a specificity of 89% for the presence of obstructive CAD. The theoretic Bayesian model predicted substantial cost savings when EBCT was used as the initial test instead of ETT, with decreasing benefit as the prevalence of disease increased (44% saving at 0% prevalence; 15% saving at 100% prevalence). In the patient cohort, the diagnostic pathway starting with EBCT provided a 45% to 65% cost saving over the ETT pathway. We conclude that in patients with low to intermediate pretest probability of disease, a pathway based on EBCT as the initial test to investigate presence of obstructive CAD provides a substantial cost benefit over a pathway based on ETT. Such cost advantages decrease as the prevalence of disease increases.

Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography.

BACKGROUND: There is a clear relationship between absolute calcium scores (CS) and severity of coronary artery disease. However, hard coronary events have been shown to occur across all ranges of CS. METHODS AND RESULTS: We conducted 2 analyses: in group A, 172 patients underwent electron-beam CT (EBCT) imaging within 60 days of suffering an unheralded myocardial infarction. In group B, 632 patients screened by EBCT were followed up for a mean of 32+/-7 months for the development of acute myocardial infarction or cardiac death. The mean patient age and prevalence of coronary calcification were similar in the 2 groups (53+/-8 versus 52+/-9 years and 96% each). In group B, the annualized event rate was 0.11% for subjects with CS of 0, 2.1% for CS 1 to 99, 4.1% for CS 100 to 400, and 4.8% for CS >400, and only 7% of the patients had CS >400. However, mild, moderate, and extensive absolute CSs were distributed similarly between patients with events in both groups (34%, 35%, and 27%, respectively, in group A and 44%, 30%, and 22% in group B). In contrast, the majority of events in both groups occurred in patients with CS >75th percentile (70% in each group). CONCLUSIONS: Coronary calcium is present in most patients who suffer acute coronary events. Although the event rate is greater for patients with high absolute CSs, few patients have this degree of calcification on a screening EBCT. Conversely, the majority of events occur in individuals with high CS percentiles. Hence, CS percentiles constitute a more effective screening method to stratify individuals at risk.

Is mitral valve prolapse due to cardiac entrapment in the chest Cavity? A CT view.

BACKGROUND: Mitral valve prolapse (MVP) is the most frequently diagnosed valvular disease, but its pathophysiology remains elusive. Its complete absence in 1,734 neonatal echocardiographic studies suggests that this may be an acquired rather than a congenital disease. We observed several patients with distorted cardiac and valvular anatomies on electron beam CT (EBCT) images of the chest who reported symptoms reminiscent of MVP. In these patients, the heart is compressed between the spine and the anterior chest wall and it appears trapped in a chest cavity that is too small for its size. METHODS: We performed EBCT in 66 patients with echocardiographically proven MVP and no clinical pectus excavatum (group A; 80% were women; mean age, 48 +/- 12 years) and in 96 control patients without MVP by echocardiography (group B; 72% were women; mean age, 49 +/- 10 years). EBCT alone was also performed on 200 patients who had reported atypical chest discomfort and palpitations to their physicians (group C) and on 200 asymptomatic patients (group D). The EBCT measurements included the following: anteroposterior chest diameter (APD); the angle formed by the confluence of the mitral valve ring with the interatrial septum (ANGLE); and the contact area between the posterior surface of the anterior chest wall and the myocardium (CA). Entrapment was considered present if the individual patient's measurements varied by more than two SDs compared to measurements made in control subjects (group B). RESULTS: EBCT images demonstrated cardiac entrapment in 82% of group A patients and in 4.2% of group B patients (p < 0.001). ANGLE and CA were significantly larger in MVP patients than in group B patients (114 +/- 9 degrees vs 91 +/- 5 degrees and 6,230 +/- 2,020 mm(2) vs 476 +/- 1,009 mm(2), respectively; p < 0.001 for both comparisons), while APD was significantly smaller (91 +/- 16 mm vs 128 +/- 17 mm, respectively; p < 0.001). The prevalence of entrapment was significantly greater in group C patients than in group D patients (22% vs 6.5%; p < 0. 001). CONCLUSIONS: MVP may be an acquired condition caused by a growth disproportion between the heart and the chest cavity, with distortion of the mitral valve annulus and subsequent leaflet prolapse. A narrow APD, a wide ANGLE, and a large CA characterize this condition. Similar findings are found in a sizable proportion of patients with atypical chest pain symptoms and palpitations.

Effect of HMG-CoA reductase inhibitors on coronary artery disease as assessed by electron-beam computed tomography.

BACKGROUND: Angiographic studies of the regression of coronary artery disease are invasive and costly, and they permit only limited assessment of changes in the extent of atherosclerotic disease. Electron-beam computed tomography (CT) is noninvasive and inexpensive. The entire coronary-artery tree can be studied during a single imaging session, and the volume of coronary calcification as quantified with this technique correlates closely with the total burden of atherosclerotic plaque. METHODS: We conducted a retrospective study of 149 patients (61 percent men and 39 percent women; age range, 32 to 75 years) with no history of coronary artery disease who were referred by their primary care physicians for screening electron-beam CT. All patients underwent base-line scanning and follow-up assessment after a minimum of 12 months (range, 12 to 15), and a volumetric calcium score was calculated as an estimate of the total burden of plaque. Treatment with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors was begun at the discretion of the referring physician. Serial measurements of low-density lipoprotein (LDL) cholesterol were obtained, and the change in the calcium-volume score was correlated with average LDL cholesterol levels. RESULTS: One hundred five patients (70 percent) received treatment with HMG-CoA reductase inhibitors, and 44 patients (30 percent) did not. At follow-up, a net reduction in the calcium-volume score was observed only in the 65 treated patients whose final LDL cholesterol levels were less than 120 mg per deciliter (3.10 mmol per liter) (mean [+/-SD] change in the score, -7+/-23 percent; P=0.01). Untreated patients had an average LDL cholesterol level of at least 120 mg per deciliter and at the time of follow-up had a significant net increase in mean calcium-volume score (mean change, +52+/-36 percent; P<0.001). The 40 treated patients who had average LDL cholesterol levels of at least 120 mg per deciliter had a measurable increase in mean calcium-volume score (25+/-22 percent, P<0.001), although it was smaller than the increase in the untreated patients. CONCLUSIONS: The extent to which the volume of atherosclerotic plaque decreased, stabilized, or increased was directly related to treatment with HMG-CoA reductase inhibitors and the resulting serum LDL cholesterol levels. These changes can be determined noninvasively by electron-beam CT and quantified with use of a calcium-volume score.

Coronary artery disease: improved reproducibility of calcium scoring with an electron-beam CT volumetric method.

PURPOSE: To assess the variability and reproducibility of a volumetric calcium score calculated with electron-bean computed tomographic (CT) scans of coronary arteries. MATERIALS AND METHODS: Two sets of electron-beam CT scans were obtained in patients with coronary calcification (group A) or known risk factors for coronary arterial disease (group B). The second set or scans was obtained after a brief interval (group A, n = 52) or after 1 year with no risk modification (group B, n = 27). Traditional (plaque area and attenuation) and volumetric calcium scores were calculated for each patient and lesion. RESULTS: The median percentage change for individual lesions in group A was 13% for the volumetric and 19% for the traditional score. The overall reduction in error with the volumetric score was 40% (P < .001). The median percentage change for group A patient totals was 9% for the volumetric and 15% for the traditional score (P < .001). In group B patients, the median volumetric score increased by 44% after 1 year. CONCLUSION: The volumetric score showed better reproducibility than the traditional score, and its variability was considerably less than the score increase in untreated patients after 1 year. The reproducibility of the volumetric method makes it useful for assessing the progression of coronary arterial disease on serial electron-beam CT studies.