Risk stratification. A practical approach to using epiluminescence microscopy/dermoscopy in melanoma screening.

Risk stratification of pigmented lesions during melanoma screening is a method of classifying lesions into groups based on their relative risk of being melanoma. Risk stratification accepts the fact that clinical examination with and without ELM is not perfect but uses potential ELM clues to early melanoma to increase the sensitivity of screening. Risk stratification permits the use of all available a priori clinical information and the physician's judgement in making a final management decision for each lesion and for each patient. Risk stratification using ELM is based on two primary concepts: (1) a pigment network suggests a lesion is melanocytic and (2) melanoma causes the network to develop heterogeneous (i.e., irregular) and eccentric (i.e., not centered) pigmentation. In applying ELM risk stratification to melanoma screening the physician follows these four steps: 1. Inspect each lesion carefully for a pigment network. 2. If a pigment network is seen, group lesions by their relative degrees of heterogeneity and eccentricity of the pigment network. 3. If a network is not seen, look for typical patterns of benign lesions and melanoma mimickers. 4. Use the resulting clinical risk class to guide management using all available clinical information combined with clinical judgment.

Teledermoscopy--results of a multicentre study on 43 pigmented skin lesions.

We performed a multicentre study to evaluate the agreement between the direct clinical diagnosis and the telediagnosis of 43 cutaneous pigmented lesions. Digital clinical and dermoscopic images of the 43 pigmented skin lesions (11 melanomas, 23 melanocytic naevi, three basal cell carcinomas, three lentigines, two seborrhoeic keratoses and one angiokeratoma) were sent by email to 11 colleagues (six dermatologists, two residents in dermatology, one oncologist, one specialist in internal medicine and one general practitioner) in 10 centres. These 11 colleagues had different degrees of experience in dermoscopy. With histopathology as the gold standard, an average of 85% of the telediagnoses were correct, with results varying from 77% to 95%, whereas face-to-face diagnosis by an expert dermatologist was correct in 91% of cases. The kappa value for all participants ranged from 0.35 to 0.87. The results confirm that teledermoscopy can be a reliable technique for the diagnosis of pigmented skin lesions but one that will depend on the expertise of the observer.

Comparison of dermatoscopic ABCD rule and risk stratification in the diagnosis of malignant melanoma.

For didactic and documentation purposes the dermatoscopic ABCD rule and the dermatoscopic risk stratification have been proposed. The aim of this investigation was to compare the ability of the 2 methods to separate patients with cutaneous malignant melanoma from individuals with other pigmented skin lesions. Three dermatologists, experienced users of dermatoscopy, assessed macroscopic clinical and dermatoscopic slides from 258 patients referred to the skin cancer outpatient clinic by the ABCD rule and risk stratification methods. Diagnostic performance of the 2 methods was compared by receiver operating characteristics curve analysis. When all pigmented skin lesions were compared, there was a trend for the observers to perform better using risk stratification. When only lesions with a well-defined pigment network were included, the diagnostic performance of the risk stratification method was superior to the dermatoscopic ABCD rule (areas under the receiver operating characteristics curve median 0.93 vs. 0.80, p<0.004) for all observers. The agreement between the 2 methods was moderate to substantial (kappa coefficient 0.53-0.62). More melanomas were identified when the rules were combined. The dermatoscopic ABCD rule has been accepted as a standard for identifying melanomas with the dermatoscope, but should be considered secondary to pigment network analysis.

Clinicopathological correlation of pigmented skin lesions using dermoscopy.

Dermoscopy (dermatoscopy, epiluminescence microscopy) is an additional measure for making the diagnosis of pigmented skin lesions more accurate. It enables the clinician to visualize features not discernible by the naked eye. By applying enhanced digital dermoscopy and a standardized gross pathology protocol to pigmented skin lesions, a precise clinicopathological correlation of relevant dermoscopic features can be made. Histological specimens of four pigmented skin lesions (melanoma in situ, Clark's nevus, Reed's nevus, seborrheic keratosis) were processed using a standardized gross pathology protocol and viewed along with the clinical photographs and digital dermoscopic images that were magnified and enhanced to better visualize the corresponding dermoscopic structures. Furthermore, measurements of dermoscopic structures using digital equipment were correlated with histometric findings. Our understanding of dermoscopic features, especially the broadened pigment network - a specific dermoscopic criterion for melanoma - was refined by this detailed case-by-case correlation. In addition, some not yet fully characterized dermoscopic features, such as black lamella, radial streaks, and exophytic papillary structures, were described in detail dermoscopically and histopathologically. Moreover, measurements of these dermoscopic features and the underlying histological structures were found to be similar. Linking dermoscopy more closely with cutaneous pathology may help refine the definitions and diagnostic criteria of pigmented skin lesions for dermatologists as well as dermatopathologists.

Ultraviolet radiation of melanocytic nevi: a dermoscopic study.

BACKGROUND: UV radiation can lead to clinical, histological, and ultrastructural changes in melanocytic nevi. In this study, we investigated whether exposure to 2 minimal erythema doses of UV radiation induces changes in the dermoscopic image of acquired melanocytic nevi. OBSERVATIONS: Fifteen melanocytic nevi were exposed to 2 minimal erythema doses of UV radiation. Differences in dermoscopic parameters (asymmetry, border, erythema, and telangiectasias in the nevus; pigmentation; hypopigmented areas; presence, regularity, and sharpness of pigment network; and brown-black globules) in digital dermoscopic images taken before and 3, 7, 14, and 28 days after UV irradiation were scored. Three days after UV irradiation, the borders of nevi were more faded (P<.02), the nevi were darker brown (P<.02), the hypopigmented areas were smaller (P<.02), and the pigment network structures were more faded (P<.007) and less prominent (P<.02) than before UV irradiation. Seven days after UV irradiation, pigmented globules have also grown (P<.05). After 28 days, all parameters, except hypopigmented areas, were essentially the same as before UV irradiation. CONCLUSION: UV irradiation of melanocytic nevi with 2 minimal erythema doses induces transient changes in their dermoscopic appearance that are sometimes suggestive of malignant melanoma.

Clinical diagnosis of pigmented lesions using digital epiluminescence microscopy. Grading protocol and atlas.

BACKGROUND AND DESIGN: Epiluminescence microscopy (ELM) is a clinical technique that permits in vivo visual inspection of pigmented anatomic structures of the epidermis, dermoepidermal junction, and papillary dermis. A protocol is proposed for systematic visual inspection of pigmented lesions. Seventy pigmented lesions were imaged with a digital ELM camera system. Images were visually inspected for eight "global" ELM features, 23 "local" ELM features, and 18 network features. An atlas of the most clinically significant ELM features is presented with pilot estimates of their sensitivity and specificity for detecting melanoma. RESULTS: Preliminary data suggest that ELM features that may be most specific for melanoma include multicomponent pattern, nodular pattern, pseudopods, radial streaming, blue-gray areas, whitish veil (milky way), and sharp network margins. Epiluminescence microscopic features that may be most sensitive for melanoma include pigment dots, peripheral erythema, peripheral dark network patches, marked mean network irregularity, network line thickness variability, radial streaming, blue-gray areas, and whitish veil (milky way). Epiluminescence microscopic features that may be most sensitive for severe melanocyte atypia include pigment dots, peripheral erythema, hypopigmented network patches, peripheral dark network patches, marked mean network irregularity, and focal absence of network. In addition, features that may have a very high specificity for benign lesions include saccular pattern (suggests hemangioma), globular pattern (suggests a compound or dermal nevus), and multiple comedolike openings (suggests seborrheic keratosis). CONCLUSIONS: Features most sensitive for severe atypia and melanoma could form the basis for a screening test for considering biopsy. Features most specific for melanoma then could be applied to further triage management of pigmented lesions that meet initial screening criteria. In addition, features with very high specificity for benign lesions may help develop ELM criteria to avoid unnecessary surgery.