"Influence of time on dermoscopic diagnosis and management"Jaimes, Natalia; Dusza, Stephen W; Quigley, Elizabeth A; Braun, Ralph P; Puig, Susana; Malvehy, Josep; Kittler, Harald; Rabinovitz, Harold S; Oliviero, Margaret C; Soyer, H Peter; Grichnik, James M; Korzenko, Adam; Cabo, Horacio; Carlos-Ortega, Blanca; Ahlgrimm-Siess, Verena; KOPF, ALFRED W; Marghoob, Ashfaq A
BACKGROUND/OBJECTIVES: Dermoscopy aids in clinical decision-making. However, time pressure is a common reason precluding its use. We evaluated the effect of time on lesion recognition and management decisions utilising clinical and dermoscopic images. METHOD: In all, 100 dermoscopic images were presented to 15 dermatologists with experience in dermoscopy and seven non-experts (dermatology residents). Each lesion was displayed thrice in succession. The dermoscopic image was initially presented for 1 s (t1). The same dermoscopic image was shown again without time constraints (t2) and then a final time with additional images of the clinical context (t3). Participants provided a diagnosis, their level of confidence and biopsy predilection after evaluating each image. RESULTS: For benign lesions, both groups rarely changed their diagnosis. However, an improvement in the number of correct benign diagnoses was observed when the lesion was shown in a clinical context. For malignant lesions, both groups improved when more time and clinical context was given; nevertheless, non-experts were more likely to change the diagnosis towards the correct one as more time was given and tended to perform more biopsies, in particular of benign lesions. Limitations were a small number of participants and an artificial study setting. CONCLUSION: Dermoscopy uses analytical and non-analytical reasoning approaches. We suggest that non-analytical reasoning is employed when rapid clinical decisions need to be made, especially during the evaluation of benign lesions. We conclude that dermoscopy is relatively rapid and non-time-consuming technique that adds relevant information and guides clinicians towards appropriate management decisions..
"Analysis of the benign to malignant ratio of lesions biopsied by a general dermatologist before and after the adoption of dermoscopy"Terushkin, Vitaly; Warycha, Melanie; Levy, Marla; KOPF, ALFRED W; Cohen, David E; Polsky, David
"Observation of Chrysalis Structures With Polarized Dermoscopy"Marghoob, AA; Cowell, L; KOPF, AW; Scope, A
"Utility of lesion diameter in the clinical diagnosis of cutaneous melanoma"Abbasi, Naheed R; Yancovitz, Molly; Gutkowicz-Krusin, Dina; Panageas, Katherine S; Mihm, Martin C; Googe, Paul; King, Roy; Prieto, Victor; Osman, Iman; Friedman, Robert J; Rigel, Darrell S; KOPF, ALFRED W; Polsky, David
OBJECTIVE: To determine the utility of the current diameter criterion of larger than 6 mm of the ABCDE acronym for the early diagnosis of cutaneous melanoma. DESIGN: Cohort study. SETTING: Dermatology hospital-based clinics and community practice offices. Patients A total of 1323 patients undergoing skin biopsies of 1657 pigmented lesions suggestive of melanoma. MAIN OUTCOME MEASURE: The maximum lesion dimension (diameter) of each skin lesion was calculated before biopsy using a novel computerized skin imaging system. RESULTS: Of 1657 biopsied lesions, 853 (51.5%) were 6 mm or smaller in diameter. Invasive melanomas were diagnosed in 13 of 853 lesions (1.5%) that were 6 mm or smaller in diameter and in 41 of 804 lesions (5.1%) that were larger than 6 mm in diameter. In situ melanomas were diagnosed in 22 of 853 lesions (2.6%) that were 6 mm or smaller in diameter and in 62 of 804 lesions (7.7%) that were larger than 6 mm in diameter. Conclusion The diameter guideline of larger than 6 mm provides a useful parameter for physicians and should continue to be used in combination with the A, B, C, and E criteria previously established in the selection of atypical lesions for skin biopsy.
"The diagnostic performance of expert dermoscopists vs a computer-vision system on small-diameter melanomas"Friedman, Robert J; Gutkowicz-Krusin, Dina; Farber, Michele J; Warycha, Melanie; Schneider-Kels, Lori; Papastathis, Nicole; Mihm, Martin C Jr; Googe, Paul; King, Roy; Prieto, Victor G; KOPF, ALFRED W; Polsky, David; Rabinovitz, Harold; Oliviero, Margaret; Cognetta, Armand; Rigel, Darrell S; Marghoob, Ashfaq; Rivers, Jason; Johr, Robert; Grant-Kels, Jane M; Tsao, Hensin
OBJECTIVE: To evaluate the performance of dermoscopists in diagnosing small pigmented skin lesions (diameter </= 6 mm) compared with an automatic multispectral computer-vision system. DESIGN: Blinded comparison study. SETTING: Dermatologic hospital-based clinics and private practice offices. Patients From a computerized skin imaging database of 990 small (</= 6-mm) pigmented skin lesions, all 49 melanomas from 49 patients were included in this study. Fifty randomly selected nonmelanomas from 46 patients served as a control. MAIN OUTCOME MEASURES: Ten dermoscopists independently examined dermoscopic images of 99 pigmented skin lesions and decided whether they identified the lesions as melanoma and whether they would recommend biopsy to rule out melanoma. Diagnostic and biopsy sensitivity and specificity were computed and then compared with the results of the computer-vision system. RESULTS: Dermoscopists were able to correctly identify small melanomas with an average diagnostic sensitivity of 39% and a specificity of 82% and recommended small melanomas for biopsy with a sensitivity of 71% and specificity of 49%, with only fair interobserver agreement (kappa = 0.31 for diagnosis and 0.34 for biopsy). In comparison, in recommending biopsy to rule out melanoma, the computer-vision system achieved 98% sensitivity and 44% specificity. CONCLUSIONS: Differentiation of small melanomas from small benign pigmented lesions challenges even expert physicians. Computer-vision systems can facilitate early detection of small melanomas and may limit the number of biopsies to rule out melanoma performed on benign lesions.
"Changes in the presentation of nodular and superficial spreading melanomas over 35 years"Warycha, Melanie A; Christos, Paul J; Mazumdar, Madhu; Darvishian, Farbod; Shapiro, Richard L; Berman, Russell S; Pavlick, Anna C; KOPF, ALFRED W; Polsky, David; Osman, Iman
GRANTS:5 P30 CA 016087-27/CA/NCI NIH HHS/United States
BACKGROUND: Nodular melanoma (NM) may be biologically aggressive compared with the more common superficial spreading melanoma (SSM), with recent data suggesting underlying genetic differences between these 2 subtypes. To better define the clinical behavior of NMs, the authors compared their clinical and histopathologic features to those of SSMs at their institution, a tertiary referral center, over 3 decades. METHODS: A total of 1,684 patients diagnosed with 1,734 melanomas were prospectively enrolled. Of these, 1,143 patients (69% SSM, 11% NM, 20% other) were diagnosed between 1972 and 1982; 541 patients (54% SSM, 23% NM, 23% other) were diagnosed between 2002 and the present. Differences between the features of NM and SSM within each time period as well as changes over time were analyzed. RESULTS: The authors found that SSMs are now diagnosed as thinner lesions (P < .0001) with a low incidence of histologic ulceration (P < .0001), whereas there was no significant change in the median tumor thickness or ulceration status of NMs over time (P = .10, P = .30, respectively). The median age at diagnosis of NM, however, did significantly increase over time (51 years to 63 years, P < .01). The median duration of NMs was reported to be only 5 months compared with 9 months in SSM patients. CONCLUSIONS: The authors' data suggest that improvements have been made in the early detection of SSM but not NM. Modifications of current screening practices, including increased surveillance of high-risk patients with an emphasis on the 'E' for 'evolution' criterion of the ABCDE acronym used for early detection of melanoma, are thus warranted.
"The significance of multiple blue-grey dots (granularity) for the dermoscopic diagnosis of melanoma"Braun, R P; Gaide, O; Oliviero, M; KOPF, A W; French, L E; Saurat, J-H; Rabinovitz, H S
BACKGROUND: The presence of multiple blue-grey dots (MBGD) is widely used by clinicians to decide if a pigmented lesion should be removed, but only little is known about their significance. OBJECTIVES: To evaluate the significance of MBGD for the dermoscopic diagnosis of melanoma. METHODS: In part 1 we retrospectively evaluated 340 pigmented lesions for the presence and morphological appearance of granularity. One hundred and seventy melanomas were included and matched with 170 benign and dysplastic naevi which were randomly chosen from our collection. In part 2, 3773 lesions were examined prospectively in at-risk patients: all lesions with granularity were recorded, surgically removed and subjected to histopathological examination. RESULTS: In part 1, granularity was found in 26.5% of the benign lesions and 93.5% of melanomas. The presence of granularity, granularity at the periphery, irregularly distributed granularity and granularity in association with red and white colour were statistically highly significant for the diagnosis of melanoma (P < 0.001). In part 2, granularity was found in 1.08% of the 3773 lesions and more frequently in sun-damaged skin. Sensitivity for the diagnosis of melanoma was 85% and specificity 99%. CONCLUSIONS: After the revision of many lesions with MBGD, we concluded that the term 'granularity' better describes this entity. Lesions with irregular granularity (periphery, irregularly distributed) should be removed especially if they are associated with red, blue or white colour. Lesions with a benign dermoscopy pattern which have granularity with a regular appearance and involving only a small portion of the lesion do not require surgical excision.
"Exclusively benign dermoscopic pattern in a patient with acral melanoma" [Letter]Braun, Ralph P; Gaide, Olivier; Skaria, Andreas M; KOPF, ALFRED W; Saurat, Jean-Hilaire; Marghoob, Ashfaq A
"The CASH (color, architecture, symmetry, and homogeneity) algorithm for dermoscopy"Henning, J Scott; Dusza, Stephen W; Wang, Steven Q; Marghoob, Ashfaq A; Rabinovitz, Harold S; Polsky, David; KOPF, ALFRED W
BACKGROUND: The color, architecture, symmetry, and homogeneity (CASH) algorithm for dermoscopy includes a feature not used in prior algorithms, namely, architecture. Architectural order/disorder is derived from current concepts regarding the biology of benign versus malignant melanocytic neoplasms. OBJECTIVE: We sought to evaluate the accuracy of the CASH algorithm. METHODS: A total CASH score (TCS) was calculated for dermoscopic images of 325 melanocytic neoplasms. Sensitivity, specificity, diagnostic accuracy, and receiver operating characteristic curve analyses were performed by comparing the TCS with the histopathologic diagnoses for all lesions. RESULTS: The mean TCS was 12.28 for melanoma, 7.62 for dysplastic nevi, and 5.24 for nondysplastic nevi. These differences were statistically significant (P < .001). A TCS of 8 or more yielded a sensitivity of 98% and specificity of 68% for the diagnosis of melanoma. LIMITATIONS: This is a single-evaluator pilot study. Additional studies are needed to verify the CASH algorithm. CONCLUSIONS: The CASH algorithm can distinguish melanoma from melanocytic nevi with sensitivity and specificity comparable with other algorithms. Further study is warranted to determine its intraobserver and interobserver correlations.
"Level of confidence in diagnosis: clinical examination versus dermoscopy examination"Benvenuto-Andrade, Cristiane; Dusza, Stephen W; Hay, Jennifer L; Agero, Anna Liza C; Halpern, Allan C; KOPF, ALFRED W; Marghoob, Ashfaq A
BACKGROUND: Confidence is an important factor in decision making and may influence patient care. OBJECTIVES: To evaluate whether short-training-based dermoscopy increases confidence in the diagnosis of skin lesions. METHODS AND MATERIALS: After a 1-hour course on dermoscopy, 20 pairs of clinical and dermoscopic images of lesions were presented to 19 dermatology residents with little or no dermoscopy experience. After viewing the clinical image, they were asked to assess their confidence in the diagnosis in a seven-point scale, with 1 reflecting that the respondent was 100% confident that the lesion was benign, while number 7 reflected 100% confidence that it was malignant. The same technique was used for dermoscopic images. RESULTS: Ten of the 20 pairs of evaluations showed a significant difference (p<.05). The largest differences were observed in lesions where clinical scores suggested that participants were uncertain about the diagnosis, but tended to decide that the lesion was benign after dermoscopy. Dermoscopy did not improve confidence in the evaluation of dysplastic lesions as well as lesions with obvious clinical diagnoses. CONCLUSIONS: Short-training-based dermoscopy improved confidence in the diagnosis of clinically challenging skin lesions, but the impact was not demonstrable for clinically obvious lesions and dysplastic nevi.
""Fat fingers:" a clue in the dermoscopic diagnosis of seborrheic keratoses"KOPF, ALFRED W; Rabinovitz, Harold; Marghoob, Ashfaq; Braun, Ralph P; Wang, Steven; Oliviero, Margaret; Polsky, David
'Fat fingers' are thick digitate linear, curvilinear, branched, or oval/circular dermoscopic structures typically seen in seborrheic keratoses where they represent the gyri of their cerebriform surfaces. Their recognition is very useful in the diagnosis of these lesions, especially when the classic features (eg, milia, comedo-like openings) are absent. Histologically and by confocal microscopy the 'fat finger' gyri are accentuated by pigmented keratin filling the sulci. 'Fat fingers' must be differentiated from other linear structures such as 'network-like structures'; branched streaks; network; globules; pigmented ovoid-nests; and streaks/pseudopods seen in different melanocytic and non-melanocytic lesions.
"Three-point checklist of dermoscopy: an open internet study"Zalaudek, I; Argenziano, G; Soyer, H P; Corona, R; Sera, F; Blum, A; Braun, R P; Cabo, H; Ferrara, G; KOPF, A W; Langford, D; Menzies, S W; Pellacani, G; Peris, K; Seidenari, S
BACKGROUND: In a pilot study, the three-point checklist of dermoscopy has been shown to represent a valid and reproducible tool with high sensitivity for the diagnosis of skin cancer in the hands of a small group of nonexperts. OBJECTIVES: To re-evaluate these preliminary results in a large number of observers independently from their profession and expertise in dermoscopy. METHODS: The study was conducted via the internet to provide worldwide access for participants. After a short web-based tutorial, the participants evaluated dermoscopic images of 165 (116 benign and 49 malignant) skin lesions (15 training and 150 test lesions). For each lesion participants scored the presence of the three-point checklist criteria (asymmetry, atypical network and blue-white structures). Kappa values, odds ratios, sensitivity, specificity and likelihood ratios were estimated. RESULTS: Overall, 150 participants joined the study. The three-point checklist showed good interobserver reproducibility (kappa value: 0.53). Sensitivity for skin cancer (melanoma and basal cell carcinoma) was 91.0% and this value remained basically uninfluenced by the observers' professional profile. Only 20 participants lacking any experience in dermoscopy performed significantly more poorly, but the sensitivity was still remarkably high (86.7%) when considering that they were untrained novices in dermoscopy. The specificity was 71.9% and was significantly influenced by the profession, with dermatologists performing best. CONCLUSIONS: Our study confirms that the three-point checklist is a feasible, simple, accurate and reproducible skin cancer screening tool.