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Background: One of the most difficult problems in the in vivo diagnosis of cutaneous tumors is the differentiation clinically between early malignant melanoma (MM) and atypical (dysplastic) melanocytic nevi (AMNs) because these lesions share clinical features. High-quality digital imaging systems and store-and-forward technology have the potential for use in a teledermatology system with which experts would be able to immediately transmit their diagnostic opinions concerning these challenging lesions. Objective: The main purpose of this study was to determine if the clinical and dermoscopic diagnoses and the dermoscopic features of AMN and early MM are unaltered after telephonic transmission of their digitized images. Methods: Conventional and dermoscopic photographic transparencies of 22 AMNs and 9 early MMs, viewed on rearview projectors and then scanned, compressed, transmitted (Internet) and viewed on color monitors, were evaluated. Results: The concordance in the diagnosis of AMN and of early MM by all four observers, both clinically and dermoscopically, when comparing rearview-projected conventional transparency slides to transmitted, compressed, digitized images, was high. For most specific dermoscopic features, the concordance was good, although less so for the presence or absence of some dermoscopic features, namely ‘dots’, ‘blue/gray’ color and ‘red’ color. Conclusion: The results reported support the conclusion that Internet transmission of digitized images of MMs and AMNs retains sufficient informativeness for diagnostic purposes. This study is a step in the creation of an international teledermoscopy network for pigmented cutaneous lesions.

BACKGROUND/AIMS Atypical melanocytic nevi (AMN) share some or all of the clinical features of malignant melanoma (MM). The clinical sensitivity for diagnosing MM by physicians experienced in evaluating pigmented lesions is reported to range from 73% to 89%. This study attempted to determine whether clinical sensitivity can be increased by dermoscopy (epilumnescence microscopy, dermatoscopy). METHODS A total of 72 melanocytic neoplasms were histologically diagnosed as either AMN or early MM (

This is a study of factors associated with late recurrence (i.e. 10 or more years after definitive surgery) of cutaneous malignant melanoma (MM). Four factors were evaluated: Breslow thickness, site of the primary MM, age of the patient at initial treatment for MM, and gender. These factors were compared between two groups: (1) Stage I cases in the New York University Melanoma Cooperative Group (NYU-MCG) database that had 'early recurrence' (less than 10 years) of MM, and (2) cases in the literature with late recurrence of MM plus five new cases reported here. Compared to the group of patients with 'early recurrence' of MM, the group of patients who had late recurrence of MM were found more likely to have thinner primary melanomas (p less than 0.001), to be younger (p less than 0.001), to be female (p = 0.001), and, for females, to have the MM located on an extremity (p = 0.017). Because late recurrence does occur and because the risk of developing a new primary MM is increased in MM patients, any patient who has had a MM should be followed for life.

Thickness is known to be an important survival prognosticator for cutaneous melanoma, but controversy exists as to whether Clark level of invasion retains prognostic significance once thickness has been accounted for. A recent proposal to eliminate Clark level from the staging system for melanoma of the American Joint Committee on Cancer (AJCC) prompted the authors to investigate whether level adds useful prognostic information to Breslow thickness. They used the data base of the New York University Melanoma Cooperative Group (NYU-MCG) Registry.The analysis was based on 919 patients with AJCC Stage I or II melanomas diagnosed between 1972 and 1982 and followed for an average of 10.9 years. Melanoma thicknesses were divided into 4 categories (or = 0.75, 0.76-1.50, 1.51-4.00, and4.00 mm). Patients were cross-classified according to tumor thickness and Clark level (II-V). For each combination of thickness and level, the Kaplan-Meier survival curve and 10-year survival proportion were computed, using death from melanoma as the outcome. The impact of Clark level on survival was evaluated for each of the thickness categories. The Cox proportional hazards model was used to assess the simultaneous effect of thickness and level on survival while controlling for other important prognostic factors, i.e., age, tumor location, and presence or absence of ulceration.Level of invasion was a significant predictor of death from melanoma in each of the four thickness categories. Likewise, in the Cox analyses, level was a significant prognostic variable, even after thickness was included in the model and regardless of whether thickness was treated as a categoric or a continuous variable.These results confirm that both tumor thickness and level of invasion are important independent prognostic factors in AJCC Stage I and II melanomas. The authors recommend that Clark levels be kept as criteria in the AJCC staging system and be included in pathology reports. [See editorial on pages 491-6, this issue.]

Recently, the Pigmented Lesion Group at the University of Pennsylvania described a 4-variable model for predicting 10-year survival for patients with primary cutaneous melanoma. The variables are tumor thickness, anatomic site of the lesion, age, and gender. The objective of the current study was to test the validity of this model, employing the large data base of the New York University Melanoma Cooperative Group.The predicted probabilities of 10-year survival for 780 patients with primary cutaneous melanoma were determined by multivariate logistic regression, using the 4 variables.The overall 10-year survival rate of the current study group was 78.4%. Of the four variables, tumor thickness, anatomic site of the lesion, and age were found to be independent predictors of survival. Although survival was better for women, gender was not a statistically significant factor in predicting 10-year survival when entered into the multivariate logistic regression model. In the current study, the probability of 10-year survival of patients with melanomas0.76 mm ranged from 93-99%, depending on the age and primary site. Age and site had more impact on the prognosis of intermediate and thick melanomas than on thin melanomas. Thus, for melanomas 0.76-1.69 mm, 1.70-3.60 mm, and thicker than 3.60 mm, the probabilities of survival ranged from 70-94%, 39-82%, and 23-68%, respectively.The wider ranges in survival rates for thicker melanomas, depending on the other variables, emphasize the importance of including variables in addition to tumor thickness in a prognostic model. Using a large data base from a medical center, the current study supports the prognostic multivariate model of the Pigmented Lesions Group of the University of Pennsylvania; however, the authors of the current study did not find gender to be statistically significant in this multivariate model.

Skin cancers are the most common cancers in humans. The American Cancer Society estimates that in the United States more than 700,000 new skin cancers are diagnosed annually. Although the majority of nonmelanoma skin cancers occur on visibly exposed anatomic areas, most malignant melanomas occur on body sites obscured by clothing. The high mortality associated with advanced melanomas emphasizes the importance of performing regular total cutaneous examinations in all patients to detect early, easily curable lesions. A number of techniques aid in these examinations: (1) physical and psychologic preparation of the patient; (2) appropriate lighting and a suitable examination table; (3) when indicated, use of Wood's light, dermoscopy, and photography. In addition, any suspicious lesion should be biopsied promptly either in parte or in toto. Lastly, the patient should be educated about the signs and symptoms of skin cancer, the role of sunlight in causing skin cancer, and the need for sun avoidance and/or protection. By heightening public awareness of the high incidence of cancers of the skin and by emphasizing the need for routine examination of the entire cutaneous surface, most cutaneous malignancies can be diagnosed early when they can be cured by simple surgical procedures.

There is an increased risk of developing cutaneous malignant melanomas (MMs) in patients with classic atypical-mole syndrome (AMS). This study compares the incidence of newly diagnosed MMs in patients with classic AMS (cases) with the incidence of newly diagnosed MMs developing in a population without classic AMS (control patients). The charts of 287 white patients with AMS and 831 white patients without AMS were reviewed for the occurrence of newly diagnosed invasive MMs during follow-up. Both cases and control patients were followed up regularly by total-body cutaneous examinations. The cumulative 10-year risk for developing newly diagnosed invasive MMs was calculated (life-table method) for each cohort.Of the 287 AMS cases, 10 developed a newly diagnosed invasive MM, resulting in a 10-year cumulative risk of 10.7%. Of the 831 control patients, two developed a newly diagnosed invasive MM, resulting in a 10-year cumulative risk of 0.62%.Patients with classic AMS, regardless of the presence of a personal and/or family history of MM, are at significantly increased risk of developing invasive MMs compared with control patients.

There are many clinical and histologic factors that are known to be valuable in predicting survival rates for patients with cutaneous malignant melanomas. Breslow thickness is considered to be the most reliable prognostic factor; however, thickness is a unidimensional measurement. A more accurate mensuration to predict biologic behavior might be one that takes into account the three-dimensional volume of the neoplasm. In a study of 35 primary malignant melanomas, the volumes of the dermal components of the tumors were calculated. Those patients with tumor volumes of 200 mm3 or less had a 91.4% 5-year disease-free survival rate, compared with survival rate of only 16.7% for those patients whose lesions had tumor volumes exceeding 200 mm3. On multivariate analysis, tumor volume exceeded thickness as a prognostic indicator. Thus, measurement of tumor volume proved to be of greater significance than thickness in predicting the outcome for patients with malignant melanomas.

The clinical features of 100 dysplastic nevi were tabulated. Although certain characteristics were present in most or all of these melanocytic nevi, there was a marked heterogeneity of other clinical features. The preponderant type of large (greater than or equal to 8 mm) melanocytic nevus in patients with classic dysplastic nevi is a papule or plaque with the following characteristics: multicoloration (various shades of tans, browns, reds, or black); slightly raised height for its broad diameter; mamillated surface; and lack of hypertrichosis. An atlas illustrates some of the clinical varieties of melanocytic nevi in this syndrome.

This is a study of factors associated with late recurrence (i.e. 10 or more years after definitive surgery) of cutaneous malignant melanoma (MM). Four factors were evaluated: Breslow thickness, site of the primary MM, age of the patient at initial treatment for MM, and gender. These factors were compared between two groups: (1) Stage I cases in the New York University Melanoma Cooperative Group (NYU-MCG) database that had 'early recurrence' (less than 10 years) of MM, and (2) cases in the literature with late recurrence of MM plus five new cases reported here. Compared to the group of patients with 'early recurrence' of MM, the group of patients who had late recurrence of MM were found more likely to have thinner primary melanomas (p less than 0.001), to be younger (p less than 0.001), to be female (p = 0.001), and, for females, to have the MM located on an extremity (p = 0.017). Because late recurrence does occur and because the risk of developing a new primary MM is increased in MM patients, any patient who has had a MM should be followed for life.

The computerized database (1955 through 1982) of the Oncology Section of the Skin and Cancer Unit of New York (NY) University Medical Center includes data on 13,878 lesions. Of these lesions, 214 were diagnosed clinically and histologically as malignant melanoma (MM). An additional 51 lesions, diagnosed clinically as other than MMs, were found histologically to be MM. Seventy-nine lesions were clinically diagnosed as MM but were found histologically to be other entities. An analysis of the clinical diagnostic accuracy showed some improvement over the three periods studied (1955 through 1963, 1964 through 1973, and 1974 through 1982). Although the diagnostic accuracy for the best period (1974 through 1982) was only 64%, the diagnosis of MM was made in 84.5% of the histologically proved cases of MM, reflecting a high degree of sensitivity.

Three groups of 24 C57BL/6J black mice were studied. One group was implanted with B16 malignant melanoma, another was implanted with mammary adenocarcinoma, and the third was not given tumor implants. After 14 to 17 days, the mice were given injections i.v. of technetium-99m sulfur colloid and killed 30 min later. Organs were weighed, and radioactivity was counted. The ratios of specific radioactivities of the spleens to those of the liver were higher only in the group of mice bearing malignant melanomas. This finding suggests that the "hot spleen" phenomenon observed in humans with malignant melanomas may be due to increased specific activity rather than increased splenic volume.

The diagnostic accuracy and index of suspicion concerning malignant melanoma were calculated based on review of 5,538 histologically examined lesions (of which 99 were melanomas) that were recorded in the Oncology Section of the Skin and Cancer Unit from 1955 to 1967. The diagnostic accuracy of the physicians in the Section was determined to be 64.4%. Thus, in almost one of every three melanomas an error in clinical diagnosis was made. This "batting average" is, however, better than those of previously published reports. The index of suspicion in relation to malignant melanoma in our series was 96%. Thus, the physicians in the Oncology Section demonstrated an appropriate awareness of this tumor. However, coupled with a diagnostic accuracy of 64%, a problem nevertheless exists in the diagnosis of this serious cutaneous cancer. Our study emphasizes the importance of having histologic verification prior to definitive radical surgery on patients with malignant melanoma.

Sixteen patients were treated for melanotic freckle of Hutchinson (lentigo maligna) with the Miescher technique of x-ray therapy. Eleven patients had no local cutaneous recurrences of persistence following x-ray therapy. Five patients had local recurrence or persistence of their lesions. Three patients developed metastatic malignant melanoma. The first of these three patients had lentigo maligna melanoma, and the second patient had a melanotic freckle with atypical cells extending down the adnexae, including the sweat apparatus to the level of the coiled portion of one sweat gland. The third patient was considered to be in a precancerous phase at the time of irradiation. Nevertheless, metastases occurred. European colleagues indicate that they have not experienced such problems in using the Miescher technique. The procedure has been abandoned in our department, pending further clarification of the discrepancy between our results and those reported by our European colleagues.

Although thin malignant melanomas, i.e., those less than 0.76 mm in thickness, of the skin generally do not metastasize, it has been recently reported that when histologic regression is present, such lesions may then have a greater propensity for dissemination. However, this was not apparent in this study in which only one melanoma metastasized in a consecutive series of 41 thin lesions which were step-sectioned and had evidence of regression histologically. Possible explanations for this discrepancy are the failure of other authors to include only step-sectioned specimens of the primary melanomas in their material and/or geographic differences in the biologic behavior of this malignant neoplasm.

Cure rates after treatment of basal cell carcinomas with curettage-electrodesiccation were compared among three groups: group A, 597 lesions treated in the Skin and Cancer Unit in 1958 to 1962; group B, 91 lesions treated in the Skin and Cancer Unit in 1970; and group C, 210 lesions treated in private practice in 1962 to 1973. The following were the five-year cumulative recurrence rates: group A, 18.8%; group B, 9.6%; and group C, 5.7%. In all three groups, there were high recurrence rates for tumors treated on the nose, paranasal areas, and forehead. Few complications occurred after curettage-electrodesiccation with the exception of hypertrophic scars. The cosmetic results following curettage-electrodesication improved with time. Curettage-electrodesiccation, when performed by experienced physicians, is a very useful modality for the treatment of basal cell carcinomas, with cure rates of over 90%, satisfactory cosmetic results, and few significant complications.

Two sisters simultaneously developed a superficial spreading malignant melanoma on their legs. Concurrently, a brother was affected with fatal metastatic melanoma. Several explanations for familial malignant melanoma are reviewed, including: 1. Genetically determined predisposition; ,2 Phenotypic and environmental factors; and 3. Infectious etiology (virus?). Relatives of patients who develop malignant melanoma spould be aware that they have a higher risk than the general population of developing this serious type of cancer.

Eight patients received superficial x-ray therapy for morphea-type basal cell carcinomas. Seven lesions did not recur. One recurrence adjacent to an irradiated field was observed; it was considered to be a geographic miss and has led us to include a wider field (10 mm) of normal-appearing skin beyond the clinical perimeter of the tumor when the lesion is ill-defined. The cosmetic results after treatment were poorer than anticipated for this schedule of radiation therapy, based on our extensive experience with other types of basal cell carcinomas. To obtain the best long-term results we believe that, where technically feasible Mohs surgery and conventional surgical excision with histologic verification of free margins are the treatments of choice for morphea-type basal cell carcinomas. However, our experience indicates that morphea-type basal-cell carcinomas can be cured with radiation therapy; therefore, x-rays have a place in the armamentarium of therapeutic modalities for this tumor if surgery is not feasible or if it is refused by the patient.

This report verifies the ability of a Prognostic Index (PI) to accurately predict 5-year survival rates for 879 Stage I cutaneous malignant melanoma (MM) patients seen at New York University Medical Center. The PI used in this study was first reported from Munich, West Germany, and is calculated from standard histologic sections by multiplying the MM thickness in millimeters (Breslow method) by the number of MM mitoses per square millimeter. A PI value of less than 19 versus greater than or equal to 19 was found to be a significant and independent prognostic variable for Stage I MM when compared with seven other predictive variables (including Breslow thickness). These PI intervals identified a subgroup of patients with MM of intermediate thicknesses (1.50-3.49 mm) whose significantly worse survival would not have been anticipated if prognosis were determined by Breslow thickness alone. For example, patients with MM 1.50 to 2.49 mm thick have a 5-year survival rate of 84.1% determined by Breslow thickness alone; however, among these patients exists a subgroup with PI greater than or equal to 19 whose survival rate is only 57.6%. This study verifies the additive usefulness of the PI in predicting survival rates of patients with Stage I cutaneous MM.

A study of the influence of the anatomical location of malignant melanoma on the prognosis of 971 patients with stage I disease disclosed specific high-, intermediate-, and low-risk sites. High-risk sites included scalp, mandibular area, midline of trunk (anterior and posterior), upper medial thighs, hands, feet (except the arches), popliteal fossae, and genitalia. The life-table-adjusted five-year disease-free survival was 54% in the high-risk locations, 79% in intermediate-risk locations, and 93% in low-risk sites. A Cox proportional hazards analysis demonstrated that the grouping of lesions by their anatomical risk location had prognostic value that was significant in a model of eight other known predictive variables (thickness, sex, age, type, level, mitotic index, ulceration, and presence of preexistent nevus). The results indicate that anatomical location of the primary melanoma is significantly associated with five-year disease-free survival.

We previously reported that polyinosinic-polycytidylic acid, a potent interferon inducer, inhibits the growth of B16 malignant melanoma in the C57BL/6 mouse. Two experiments were done to evaluate the effectiveness of interferon in tumor inhibition in vivo. In the first, mice were implanted with melanoma and divided into four groups, according to treatment: interferon preparation; interferon control preparation ("breakthrough fraction"); phosphate-buffered saline control; and murine serum albumin control. Daily, each mouse was given i.p. injections of 200,000 NIH reference units (hereafter called units) of interferon or of one of the control substances. The second experiment was similar to the first, except that bovine serum albumin was an additional control. In both experiments, the average tumor volume in interferon-treated mice was statistically significantly smaller than that of each control group. Mouse interferon preparations also inhibited the multiplication of B16 malignant melanoma cells in culture. This inhibition was statistically significant from interferon levels as low as 5 to as high as 5000 units/ml. The degree of inhibition markedly increased from 5 up to 500 units, the inhibition reaching its maximum at this concentration. The inhibitory effect of interferon was abrogated by anti-murine interferon serum produced in a rabbit. These findings suggest that the in vivo inhibition of the growth of B16 melanoma demonstrated with polyinosinicpolycytidylic acid and with exogenous interferon probably results, at least in part, from a direct effect of interferon on the tumor cells themselves.

In a clinicohistopathologic study of 557 patients with primary cutaneous malignant melanoma, there were fewer metastases and/or deaths from melanoma when histologic evidence of a coexisting acquired melanocytic nevus was found. A total of 130 patients with melanocytic nevus and 427 cases of melanoma without histologic evidence of a nevus (denovo) were studied. Clinical follow-up evaluation for evidence of metastases and/or death was obtained. Only ten of the patients (7.7%) with nevus-associated melanoma had metastases and/or death v 78 (18.3%) with de novo melanoma. When stratified by lesion thickness, the logrank test for survival revealed a statistically significant difference between the two groups. An overall favorable outcome seen in patients with malignant melanomas associated with acquired melanocytic nevi was found, therefore, to be independent of lesion thickness as well as six other variables reported to be related to the biologic behavior of malignant melanoma. Thus, the presence of nevus cells in a specimen of malignant melanoma portends a better prognosis and may have important implications in the biology of this neoplasm.

Hazard-rate analysis provides a unique means of assessing prognosis in patients with malignant disease. The hazard rate is the probability of a patient dying within a particular unit of time after definitive therapy. Hazard-rate analysis was performed on a series of 719 consecutive patients with clinical stage I cutaneous malignant melanoma (MM). The peak hazard rate for death from metastatic MM occurred during the 48th month of follow-up. Thereafter, the hazard rate declined and approached zero by the 120th month. When the patients were stratified by the thickness of their primary MM, thicker lesions reached their peak hazard-rate month earlier than thinner lesions. We conclude that after 120-month survival, the risk of dying from MM is virtually zero. However, since rare late deaths from MM occur, lifetime follow-up is recommended.

A primary cutaneous myxosarcoma of the skin developed at the site from which an epithelial cyst had been excised. Following this surgical excision a "keloid" developed which was injected with intralesional corticosteroids. At this site an enlarging tumor developed which was initially thought to be myxoma on the histologic examination but subsequently gave rise to a solitary lymphnode metastasis. Wide local excision of the primary lesion with skin graft and radical axillary lymphadenectomy resulted in cure. Now, nine years post surgery the only problem that remains is repeated bouts of acute cellulitis in the slightly lymphe dematous upper extremity. Myxosarcomas of the skin are rare tumours. Metastases from such lesions are exceedingly rare.