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The COVID-19 pandemic has severely hampered the functioning of any health system, absorbing a considerable amount of resources and with the threat of widespread infection in the health services. The present survey has been carried out in Italy to evaluate if and how COVID-19 also affected skin melanoma management. We enrolled 13 Italian centres highly qualified in the diagnosis and care of skin melanoma. We compared a set of information evaluating the amount of activity for melanoma performed during February-April 2020 with the same quarter in 2019. The number of new melanoma diagnosis, biopsies, wide local excisions, overall pathology reports decreased. However, the most severe cases seem promptly managed with sentinel lymph node biopsies, new systemic treatments (north) and the total number of (advanced) treated patients (centre-south). The COVID-19 experience has underlined the need to exploit the help which may come from telemedicine.

Amelanotic/hypomelanotic melanoma (AHM) is a subtype including melanomas with little or no melanin pigmentation, amelanotic melanoma (AM); it represents 2-8 % of all melanomas.(1-2) AM may be difficult to diagnose because of lack of pigmentation and symmetry: recently, germline mutations have been reported in the MC1R gene and to a certain extent also in the MITF gene.(3) (This article is protected by copyright. All rights reserved.)

Background Nodular melanoma (NM), representing 10-30% of all melanomas, plays a major role in global mortality related to melanoma. Nonetheless, the literature on dermoscopy of NM is scanty. Objectives To assess odds ratios (ORs) to quantify dermoscopic features of pigmented NM vs. pigmented superficial spreading melanoma (SSM), and pigmented nodular nonmelanocytic and benign melanocytic lesions. Methods To assess the presence or absence of global patterns and dermoscopic criteria, digitized images of 457 pigmented skin lesions from patients with a histopathological diagnosis of NM (n = 75), SSM (n = 93), and nodular nonmelanocytic and benign melanocytic lesions (n = 289; namely, 39 basal cell carcinomas, 85 seborrhoeic keratoses, 81 blue naevi, and 84 compound/dermal naevi) were retrospectively collected and blindly evaluated by three observers. Results Multivariate analysis showed that ulceration (OR 4·07), homogeneous disorganized pattern (OR 10·76), and homogeneous blue pigmented structureless areas (OR 2·37) were significantly independent prognostic factors for NM vs. SSM. Multivariate analysis of dermoscopic features of NM vs. nonmelanocytic and benign melanocytic lesions showed that the positive correlating features leading to a significantly increased risk of NM were asymmetric pigmentation (OR 6·70), blue-black pigmented areas (OR 7·15), homogeneous disorganized pattern (OR 9·62), a combination of polymorphous vessels and milky-red globules/areas (OR 23·65), and polymorphous vessels combined with homogeneous red areas (OR 33·88). Conclusions Dermoscopy may be helpful in improving the recognition of pigmented NM by revealing asymmetric pigmentation, blue-black pigmented areas, homogeneous disorganized pattern and abnormal vascular structures, including polymorphous vessels, milky-red globules/areas and homogeneous red areas. What's already known about this topic? Nodular melanoma (NM) often exhibits features associated with deep tumour extension and less commonly displays the classic dermoscopic features of superficial spreading melanoma (SSM). What does this study add? The study identifies dermoscopic features that are significantly associated with pigmented NM compared with pigmented SSM and nonmelanoma nodular lesions. This study validates, with a multivariate analysis, the dermoscopic features leading to a significantly increased likelihood of a diagnosis of pigmented NM.

Background Nodular melanoma (NM) accounts for most thick melanomas and because of their frequent association with ulceration, fast growth rate and high mitotic rate, contribute substantially to melanoma-related mortality. In a multicentric series of 214 primary melanomas including 96 NM and 118 superficial spreading melanoma (SSM), histopathological features were examined with the aim to identify clinicopathological predictors of recurrence. Methods All consecutive cases of histopathologically diagnosed primary invasive SSM and NM during the period 2005–2010, were retrieved from the 12 participating Italian Melanoma Intergroup (IMI) centers. Each center provided clinico-pathological data such as gender, age at diagnosis, anatomical site, histopathological conventional parameters, date of excision and first melanoma recurrence. Results Results showed that NM subtype was significantly associated with Breslow thickness (BT) at multivariate analysis: [BT 1.01–2 mm (OR 7.22; 95% CI 2.73–19.05), BT 2.01–4 mm (OR 7.04; 95% CI 2.54–19.56), and BT > 4 mm (OR 51.78; 95% CI 5.65–474.86) (p 5 mitoses/mm2 (OR 4.87; 95% CI 1.77–13.40) (p = 0.002)]. The risk of recurrence was not significantly associated with NM histotype while BT [BT 1.01–2.00 mm (HR 1.55; 95% CI 0.51–4.71), BT 2.01–4.00 mm (HR 2.42; 95% CI 0.89–6.54), BT > 4.00 mm. (HR 3.13; 95% CI 0.95–10.28) (p = 0.05)], mitotic rate [MR > 2 mitoses/mm2 (HR 2.34; 95% CI, 1.11–4.97) (p = 0.03)] and the positivity of lymph node sentinel biopsy (SNLB) (HR 2.60; 95% CI 1.19–5.68) (p = 0.007) were significantly associated with an increased risk of recurrence at multivariate analysis. Conclusions We found that NM subtype was significantly associated with higher BT and MR but it was not a prognostic factor since it did not significantly correlate with melanoma recurrence rate. Conversely, increased BT and MR as well as SNLB positivity were significantly associated with a higher risk of melanoma recurrence.

The frequency of atopic dermatitis in Italian children and its relationship with selected variables were analysed in a large survey of skin health conducted in Italy. In 1997 we conducted a survey on schoolchildren aged 12–17 years from 13 areas of northern, central and southern Italy. For the present analyses, 3179 Caucasian children (1618 males, 1561 females) were considered. A diagnosis of atopic dermatitis was reported in 224 cases (7.0%). The frequency of reported atopic dermatitis was significantly higher in children with asthma (rate ratio (RR) 4.5; 95% confidence interval (CI) 3.1–6.5). The lifetime prevalence of a diagnosis of atopic dermatitis was higher among schoolchildren reporting a diagnosis of psoriasis (RR 5.5, 95% CI 3.0–10.1) and vitiligo (RR 16.1, 95% CI 6.5–39.5). This study gives estimates of the lifetime prevalence of atopic dermatitis in adolescents in Italy and emphasizes the direct association between the condition and other immune-related skin diseases.

Education campaigns to encourage self-examination coupled with rapid access to specialized dermatological clinics is considered the key strategy in the realization of early detection of cutaneous melanoma and non-melanoma skin cancer (NMSC). An alternative to an initial visit to the family doctor is open access to a skin cancer clinic at the decision of the individual. This approach has been followed mainly in countries with high melanoma incidence where the majority of the population is of northern European origin. However, the efficacy of this system has not been well established because there are few studies involving systematic follow up of individuals with positive screening through pathological confirmation of the diagnosis. We report the follow up data focussed on melanoma and NMSC detection rates in more than 1,000 subjects examined at numerous 1-day, open access clinics on the occasion of the Italian nation-wide "Skin Cancer Day" campaign promoted by the Federation of Italian Dermatological Societies. Total body skin examination was performed on all subjects, and surgical excision of a lesion was recommended in 41 of the 1042 subjects (3.9 %). Histologic diagnosis, available for 39/41 lesions, evidenced 3 superficial spreading melanomas (1 in situ, one "thin" lesion, ie. 0.30 mm in thickness, and one "thick" lesion, with a thickness of 4.53 mm) and 6 NMSC (5 BCC and 1 SCC). Thus, the prevalence of skin cancer (melanoma and NMSC) in this group was 0.8 % (9/1042), and the prevalence of melanoma was 3/1042, 0.2 %, rather similar to that found in populations of northern European origin. Open access to skin cancer clinics may represent an alternative approach to melanoma prevention also in southern European populations. Increased public awareness regarding skin cancer probably represents the main effect of this type of campaign.

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Background: Recent studies have shown an increasing incidence of cutaneous adnexal carcinomas (CACs). Objectives: The aim of our study was to evaluate incidence and survival for cases of CACs and investigate their association with other skin neoplasms. Methods: We conducted a population-based study. Data on incident cases of CACs were obtained from the Tuscany Cancer Registry between 1985 and 2010. In order to determine whether the occurrence of squamous cell carcinoma (SCC) among patients with CAC is higher or lower than expected in the general population, the standardized incidence ratio (SIR) was calculated. Results: A total of 242 patients with CAC were observed; the age-standardized incidence rate was 3·8 cases per million person-years. From 1997 to 2010 crude incidence rates increased by 159%. Age-specific incidence was higher in men over 80 years old than in women of the same age and younger individuals. Carcinomas of sweat gland origin prevailed; the most common histotype was porocarcinoma and the most frequently affected site was the head/neck. Overall, 88% of CACs were diagnosed at a localized stage. The 5-year overall survival and disease-specific survival rates were 59% [95% confidence interval (CI) 53–65] and 94% (95% CI 91–98), respectively. In the observation cohort, the number of SCCs was significantly higher than expected as the SIR was calculated to be 33·7 (P < 0·001). Conclusions: Increasing incidence warrants awareness and early diagnosis of CACs. Increased SCC incidence among patients with these tumours highlights the relevance of careful skin examination and follow-up.

Two round tables involving experts were organized in order to reach a consensus on the management of patients with actinic keratosis (AK). In the first, seven clinical questions were selected and analyzed by a systematic literature review, using a Population, Intervention, Control, and Outcomes framework; in the second, the experts discussed relevant evidences and a consensus statement for each question was developed. Consensus was reached among experts on how to best treat AK patients with respect to different clinical scenarios and special populations. Lesion-directed treatments are preferred in patients with few AKs. Patients with multiple AKs are challenging, with more than one treatment usually needed to achieve complete lesion clearance or a high lesion response rate, therapy should be personalized, based on previous treatments, patient, and lesion characteristics. Methyl aminolevulinate-PDT, DL (day light) PDT, and imiquimod cream were demonstrated to have the lowest percentage of new AKs after post treatment follow-up. For IMQ 5% and 3.75%, a higher intensity of skin reactions is associated with higher efficacy. Photodynamic therapy (PDT) is the most studied treatment for AKs on the arms. Regular sunscreen use helps preventing new AKs. Oral nicotinamide 500 mg twice daily, systemic retinoids and regular sunscreen use were demonstrated to reduce the number of new squamous cell carcinomas in patients with AKs. Limited evidence is available for the treatment of AKs in organ transplant recipients. There is no evidence in favor or against the use of any of the available treatments in patients suffering from hematological cancer.

The fluorescence-advanced videodermatoscopy (FAV) is a new noninvasive method for in vivo skin examination. In a series of 6 flat melanocytic pigmented lesions(3 melanomas and 3 melanocytic naevi), FAV allowed a correct characterization between benign and malignant lesions, showing that types of cell clusters were more frequently represented in different kinds of lesions. Despite the limitations of our study due to the small number of cases, these observations lead us to think that FAV may represent a new noninvasive investigative method in studying cellular resolution melanocytic pigmented lesions.

La lettera parla delle controversie nei confronti della teledermatologia vista come metodo di screening per i tumori cutanei

Objective: Small- and intermediate-sized congenital nevi (SCN and ICN) undergo periodic clinical monitoring or surgical excision. We analyzed the management of SCN and ICN in the Italian hospital network. Methods: A nationwide survey of a representative sample of centers was conducted. Data were analyzed grouping centers by melanoma incidence into high-volume (>25 diagnoses per year) and low-volume (≤25 diagnoses per year). Results: In the pediatric population, 11% of SCN and 22% of ICN are excised, the remainder undergoing clinical monitoring at intervals of 6 months to 2 years (SCN) and of 6 months to 1 year (ICN). In adults, 24% of SCN and 41% of ICN are excised. Clinical monitoring of SCN varies from 6-monthly (most common among low-volume hospitals) to every 2 years; preferred strategies for ICN are follow-up at 1 year (51%) or follow-up at 6 months (42%). For prophylactic surgery, complete excision is preferred. Conclusions: The Italian hospital network values management and treatment of SCN and ICN. In most cases natural evolution prompts prophylactic excision. Clinical examination is an important monitoring tool, though follow-up frequency depends on the clinician's experience and practice.

Background: Most studies on dermoscopy of acral lesions were conducted in Asian populations. In this study, we analyzed these features in a predominantly Caucasian population. Objective: Estimate the prevalence of dermoscopic features in acral lesions, and assess their level of agreement between observers. Methods: In this retrospective multicenter study, 167 acral lesions (66 melanomas) were evaluated for 13 dermoscopic patterns by 26 physicians, via a secured Internet platform. Results: Parallel furrow pattern, bizarre pattern, and diffuse pigmentation with variable shades of brown had the highest prevalence. The agreement for lesion patterns between physicians was variable. Agreement was dependent on the level of diagnostic difficulty. Conclusion: Lesions with a diameter >1 cm were more likely to be melanoma. We found as well that a benign pattern can be seen in parts of melanomas. For this reason one should evaluate an acral lesion for the presence of malignant patterns first.

Background: The negative pigment network (NPN) is seen as a negative of the pigmented network and it is purported to be a melanoma-specific structure. Objectives: We sought to assess the frequency, sensitivity, specificity, and odds ratios (ORs) of NPN between melanoma cases and a group of control lesions. Methods: Digitalized images of skin lesions from 679 patients with histopathological diagnosis of dermatofibroma (115), melanocytic nevus (220), Spitz nevus (139), and melanoma (205) were retrospectively collected and blindly evaluated to assess the presence/absence of NPN. Results: The frequency of occurrence of NPN was higher in the melanoma group (34.6%) than in Spitz nevus (28.8%), melanocytic nevus (18.2%), and dermatofibroma (11.3%) groups. An OR of 1.8 emerged for the diagnosis of melanoma in the presence of NPN as compared with nonmelanoma diagnosis. Conversely, for melanocytic nevi and dermatofibromas the OR was very low (0.5 and 0.3, respectively). For Spitz nevi the OR of 1.1 was not statistically significant. When comparing melanoma with dermatofibroma, melanocytic nevus, and Spitz nevus, we observed a significantly higher frequency of multicomponent pattern (68.1%), asymmetric pigmentation (92.9%), irregularly distributed NPN (87.3%), and peripheral location of NPN (66.2%) in melanomas. Limitations: Further studies can provide the precise dermoscopic-histopathologic correlation of NPN in melanoma and other lesions. Conclusions: The overall morphologic pattern of NPN, such as the irregular distribution and the peripheral location of NPN, along with the multicomponent pattern and the asymmetric pigmentation could be used as additional features in distinguishing melanoma from Spitz nevus and other benign lesions. © 2012 by the American Academy of Dermatology, Inc.

Objective: To analyze routine clinical management of atypical melanocytic lesions through monitoring or surgery in Italian hospitals. Methods: A nationwide survey of clinical practices was conducted. Results: Digital monitoring is performed in most Italian hospitals and is preferred over excision for single atypical melanocytic lesions in 82% of hospitals. For multiple atypical lesions, 60% of high-volume hospitals prefer digital monitoring to surgical excision (40%). There is a statistically significant difference between high- and low-volume hospitals (60 vs. 39%; p = 0.003). Digital monitoring is performed at mean intervals of 4/5 months for both types of lesions. Conclusions: We show an asymmetric relation between application of the method and practical impact based on available clinical evidence. Although digital monitoring provides better characterization of the evolution of melanocytic lesions, our results indicate that the advantages and limitations of this method require further investigation.

Objective: To evaluate organizational structure and diagnostic procedures used by the Italian hospital network for identifying cutaneous melanoma. Methods: A nationwide survey of a representative sample of centers was conducted. Results: Diagnosis occurs mainly in ambulatory dermatology clinics (91%). In all high-volume hospitals, clinical and dermoscopic examination is available at first consultation or as an additional service, compared to 89% of low-volume hospitals. Computer-assisted videodermoscopy is available in 75% of hospitals, with a statistically significant difference between high- and low-volume hospitals (86 vs. 62%; p < 0.001). First consultation is generally an integrated clinical/dermoscopic evaluation (55% of high-volume centers vs. 47% of low-volume hospitals); digital evaluation is available for monitoring suspicious lesions and high-risk patients in 25% of high-volume centers versus 19% of low-volume centers. Conclusions: The organizational structure and diagnostic procedures in Italian hospitals are in line with modern diagnostic procedures for early diagnosis of melanoma. Dermatologists have a central role in managing diagnosis of primitive melanoma.

Objective: In melanoma, the surgical approach is important for both diagnosis and therapy. Although surgery is relatively simple, the methods should be performed by experts in melanoma management. We analyze the techniques and methods used in the Italian hospital network for suspicious skin lesions and confirmed melanomas. Methods: A nationwide survey was conducted of a representative sample of 120 hospitals with ≥200 beds. Results: Excision biopsies remove suspected melanomas. However, some approaches to excision margins and sentinel lymph node procedures differ from international protocols. Overall, 21% of centers perform excisional biopsy of a suspicious lesion using 1 cm margins, and 22% of centers perform sentinel node procedures concurrently with removal of primary melanoma. Conclusions: Standardized treatment protocols are needed for suspicious lesions and clinically evident melanoma, particularly regarding the critical aspect of excision margins. The sentinel lymph node procedure may be distorted by initial margins that are too wide.

Background: Identification of the clinical behavior of atypical Spitzoid tumors with conflicting histopathologic features remains controversial. Objective: We sought to assess whether molecular findings may be helpful in the diagnostic and prognostic assessment of atypical Spitzoid tumors. Methods: A total of 38 controversial, atypical Spitzoid lesions (1 mm in thickness) were analyzed for clinicopathological features, chromosomal alterations by fluorescence in situ hybridization (FISH) analysis (RREB1/MYB/CCND1/CEP6), BRAF(V600E) mutation by allele-specific real-time polymerase chain reaction confirmed by sequencing, and H-RAS gene mutation by direct sequencing. Results: Atypical Spitzoid lesions developed in 21 female and 17 male patients (mean age 22 years). Nine patients underwent sentinel lymph node biopsy and a sentinel lymph node micrometastasis was detected in 4 of these 9 cases. Four additional patients, who did not receive a sentinel lymph node biopsy, experienced bulky lymph node metastases and one experienced visceral metastases and death. Lesions from patients with lymph node involvement showed more deep mitoses (P < .01), less inflammation = .05), and more plasma cells (P = .04). FISH analysis demonstrated the presence of chromosomal alterations in 6 of 25 cases. Correlation with follow-up data showed that the only case with fatal outcome showed multiple chromosomal alterations by FISH analysis. BRAF(V600E) mutation was detected in 12 of 16 cases (75%) and H-RAS mutation on exon 3 was found in 3 of 11 cases (27%). Limitations: Our results require validation in a larger series with longer follow-up information. Conclusions: FISH assay may be of help in the prognostic evaluation of atypical Spitzoid tumors. Diagnostic significance of BRAF(V600E) and H-RAS mutations in this setting remains unclear. (J Am Acad Dermatol 2011;64:919-35)

In this study, dermatoscopic examination of 24 dermatofibromas was performed to evaluate specific dermoscopic criteria. A central white scarlike patch was appreciable in 22 of 24 lesions, whereas 20 of 24 dermatofibromas exhibited a delicate pigment network at the periphery. This stereotypical dermatoscopic finding allowed the diagnosis of dermatofibroma in most instances. (J Am Acad Dermatol 2000;43:1123-5.).

We present the case of a woman with diabetes insipidus with subsequent genital and multiorgan Langerhans cell histiocytosis (LCH). A monolateral and slightly infiltrated erythematous plaque of the vulva was observed. Hematoxylin and eosin and immunophenotypic studies were performed. The primary antibodies used were monoclonal antibody to S100, CD1a, CD34, HLA-DR, PCNA, CD45Ro, CD40, and langerin. The histology of the infiltrates revealed a granulomatous reaction pattern, with extensive aggregates of histiocyte proliferation. The histiocytes, morphologically characterized by a pale staining of cytoplasm surrounding a grooved reniform nucleus, sometimes contained small distinct nucleoli. Lymphocytes, eosinophils, macrophages, and both plasma cells and giant cells typically infiltrated the lesions. Cells CD1a+ and S100+ infiltrated the epidermic and were dispersed over the infiltrates as well as in clusters, and around the vessels. A considerable number of CD40-expressing cells were restricted to CD1a+ LCH cells. The specimen contained a high percentage of langerin+ cells in both the dermis and the epidermis. The clinical manifestations of LCH affecting the genital area can be diverse, and in most patients take the form of ulcers or erythematous plaques. Histopathologic examination of the lesion evidences a mixture of Langerhans cell histiocytes (CD1a+, S100+, HLADr+, CD207+, CD 40+), lymphocytes (predominantly helper [CD4] CD 45 Ro+), eosinophils, and macrophages. Each of the cell types produces a “cytokine storm.” Many of the cytokines favor recruitment of Langerhans cell progenitors and rescue the Langerhans cell histiocytes from apoptosis.

Self-detection of suspicious pigmented skin lesion combined with rapid referral to dermatologic centres is the key strategy in the fight against melanoma. The investigation of factors associated with pattern of detection of melanoma (self- vs. nonself-detection) may be useful to refine educational strategies for the future. We investigated the frequency of melanoma self-detection in a Mediterranean population at intermediate melanoma risk. A multicentric survey identified 816 consecutive cases of cutaneous melanoma in the period January to December 2001 in 11 Italian clinical centres belonging to the Italian Multidisciplinary Group on Melanoma. All patients filled a standardized questionnaire and were clinically examined by expert dermatologists. Self-detected melanomas were 40.6%, while the remaining lesions were detected by a dermatologist (18.5%), the family physician (15.2%), other specialists (5%), the spouse (12.5%), a friend or someone else (8.2%). Variables associated with self-detected melanomas were female sex, young age, absence of atypical nevi, knowledge of the ABCD rule, habit of performing skin self-examination. Self-detected melanomas did not differ from nonself-detected tumours in term of lesion thickness; however, patients with self-detected melanomas waited a longer period before having a diagnostic confirmation (patient's delay) (> 3 months: odds ratio, 3.89; 95% confidence interval, 2.74-5.53). In order to reduce the patients' delays, educational messages should adequately stress the need for a prompt referral to a physician once a suspicious pigmented lesion is self-detected.

Background: There is a need for better standardization of the dermoscopic terminology in assessing pigmented skin lesions. Objective: The virtual Consensus Net Meeting on Dermoscopy was organized to investigate reproducibility and validity of the various features and diagnostic algorithms. Methods: Dermoscopic images of 108 lesions were evaluated via the Internet by 40 experienced dermoscopists using a 2-step diagnostic procedure. The first-step algorithm distinguished melanocytic versus nonmelanocytic lesions. The second step in the diagnostic procedure used 4 algorithms (pattern analysis, ABCD rule, Menzies method, and 7-point checklist) to distinguish melanoma versus benign melanocytic lesions. κ Values, log odds ratios, sensitivity, specificity, and positive likelihood ratios were estimated for all diagnostic algorithms and dermoscopic features. Results: Interobserver agreement was fair to good for all diagnostic methods, but it was poor for the majority of dermoscopic criteria. Intraobserver agreement was good to excellent for all algorithms and features considered. Pattern analysis allowed the best diagnostic performance (positive likelihood ratio: 5.1), whereas alternative algorithms revealed comparable sensitivity but less specificity. Interobserver agreement on management decisions made by dermoscopy was fairly good (mean κ value: 0.53). Conclusion: The virtual Consensus Net Meeting on Dermoscopy represents a valid tool for better standardization of the dermoscopic terminology and, moreover, opens up a new territory for diagnosing and managing pigmented skin lesions. (J Am Acad Dermatol 2003;48:679-93.) J Am Acad Dermatol 2003;48:679-93.

Background Epiluminescence microscopy (ELM) (dermoscopy, dermatoscopy) is a technique for non-invasive diagnosis of pigmented skin lesions that improves the diagnostic performance of dermatologists. Little is known about the possible influence of associated clinical features on the reliability of dermoscopic diagnosis during in vivo examination. Objective To compare diagnostic performance of in vivo dermoscopy (combined clinical and dermoscopic examination) with that of dermoscopy performed on photographic slides (pure dermoscopy). Design This case series comprised 256 pigmented skin lesions consecutively identified as suspicious or equivocal during examination in a general dermatological clinic. Clinical examination and in vivo dermoscopy were performed before excision by two trained dermatologists. The same observers carried out dermoscopy on photographic slides at a later time, and these three diagnostic classifications were reviewed together with the histological findings for the individual lesions. This was carried out in a university hospital. Results In vivo dermoscopy performed better than dermoscopy on photographic slides for classification of pigmented skin lesions compared with histological diagnosis, and both performed better than general clinical diagnosis. In vivo dermoscopic diagnosis of melanoma showed 98.1% sensitivity, 95.5% specificity and 96.1% diagnostic accuracy while dermoscopic diagnosis of melanoma on photographic slides was less reliable with 81.5% sensitivity, 86.7% specificity and 85.2% diagnostic accuracy. In particular, diagnosis of melanoma based on photographic slides led to nine false negative cases (three in situ, six invasive; thickness ranges 0.2-1.5 mm). Conclusions In vivo dermoscopy, i.e. combined clinical and dermoscopic examination, is more reliable than dermoscopy on photographic slides. In clinical practice, therefore, in vivo dermoscopy cannot be considered independent from associated clinical characteristics of the lesions, which help the trained observer to reach a more precise classification. This may have implications on the reliability of ELM diagnosis made by an observer not fully trained in the clinical diagnosis of pigmented skin lesions or by a remote observer during digital ELM teleconsultation.

Background : Melanoma thickness measured according to the Breslow method is used to determine surgical margin and in patient selection for sentinel node biopsy. Previous studies did not confirm the reliability of melanoma palpability for clinical prediction of tumor thickness. Recently we reported the usefulness of epiluminescence microscopy (dermatoscopy) for in vivo detection of the phases of melanoma progression, as well as tumor depth. Objective : Our purpose was to determine whether the combination of clinical and dermatoscopic criteria could increase the accuracy in preoperative evaluation of melanoma thickness with respect to the clinical elevation and dermatoscopic assessments considered separately. Methods : In a blind retrospective study, 122 cutaneous melanomas were studied to evaluate the presence of several clinical and dermatoscopic criteria and their relation with the histologic thickness. An algorithm of combined criteria was constructed and statistically assessed. Results : Combinations of palpability, diameter of more than 15 mm, pigment network, gray-blue areas, and atypical vascular pattern allowed correct prediction of thickness in 89% of melanomas when categorized in two groups of less than 0.76 mm and more than 0.75 mm thickness, compared with 75% using palpability, and 80% using dermatoscopic criteria. Lower values were obtained in the further subdivision of melanomas into groups of 0.76 to 1.5 mm and more than 1.5 mm thickness. Conclusion : The combination of clinical and dermatoscopic criteria is a more precise guide for the preoperative evaluation of melanoma thickness than either is alone. However, further studies are needed to verify its applicability in establishing the surgical approach to cutaneous melanoma. (J Am Acad Dermatol 1999;40:61-8.)

Objective To compare the reliability of a new 7-point checklist based on simplified epiluminescence microscopy (ELM) pattern analysis with the ABCD rule of dermatoscopy and standard pattern analysis for the diagnosis of clinically doubtful melanocytic skin lesions. Design In a blind study, ELM images of 342 histologically proven melanocytic skin lesions were evaluated for the presence of 7 standard criteria that we called the "ELM 7-point checklist." For each lesion, "overall" and "ABCD scored" diagnoses were recorded. From a training set of 57 melanomas and 139 atypical non-melanomas, odds ratios were calculated to create a simple diagnostic model based on identification of major and minor criteria for the "7-point scored" diagnosis. A test set of 60 melanomas and 86 atypical non-melanomas was used for model validation and was then presented to 2 less experienced ELM observers, who recorded the ABCD and 7-point scored diagnoses. Settings University medical centers. Patients A sample of patients with excised melanocytic lesions. Main Outcome Measures Sensitivity, specificity, and accuracy of the models for diagnosing melanoma. Results From the total combined sets, the 7-point checklist gave a sensitivity of 95% and a specificity of 75% compared with 85% sensitivity and 66% specificity using the ABCD rule and 91% sensitivity and 90% specificity using standard pattern analysis (overall ELM diagnosis). Compared with the ABCD rule, the 7-point method allowed less experienced observers to obtain higher diagnostic accuracy values. Conclusions The ELM 7-point checklist provides a simplification of standard pattern analysis because of the low number of features to identify and the scoring diagnostic system. As with the ABCD rule, it can be easily learned and easily applied and has proven to be reliable in diagnosing melanoma.

Background: Cutaneous melanoma develops through a series of evolutionary steps (intraepidermal, radial, and vertical growth phases) that are traceable in specific histologic features. Epiluminescence microscopy (ELM) is an in vivo technique that enables the visualization of morphologic structures in pigmented lesions correlated with specific histologic architectural characteristics. Many ELM criteria associated with cutaneous melanoma have been described, but their correlation with tumor progression has not yet been established. Objective: In this preliminary study our purpose was to explore the possibility of recognizing ELM criteria that allow the in vivo detection of the various phases of melanoma progression as well as tumor depth. Methods: Seventy-two cutaneous melanomas (41 ''thin'' melanomas [TnM], < 0.76 mm thickness, and 31 ''thick'' melanomas [TkM], > 0.75 mm thickness) were investigated with ELM for the presence of nine standard ELM criteria; their significance was determined by calculating the chi-square test of independence. Results: A significant association is found between the presence of pigment network and TnM and between the presence of gray-blue areas, vascular pattern, and TkM. Moreover, pigment network plus radial streaming is the most significant association of ELM criteria in TnM, whereas gray-blue areas plus vascular pattern is the greatest in TkM. Conclusion: This study shows a good correlation between certain ELM criteria and the histologic architecture of cutaneous melanoma for a preoperative evaluation of the tumor thickness. Further investigation is needed for verifying on a larger number of cases our pilot estimates of sensitivity and specificity of ELM criteria in thin and thick melanomas.

Aims and background Dermoscopy (dermatoscopy, skin surface microscopy, epiluminescence microscopy) has been increasingly employed in recent years for the preoperative detection of cutaneous melanoma, and dermatoscopic features of pigmented skin lesions have been previously defined using histopathology (HP) as the “key to the code”. The aim of the present study was to evaluate the interobserver agreement on the HP diagnosis in a series of epiluminescence microscopy equivocal melanocytic skin lesions. Study design Ten melanocytic skin lesions were selected on the basis of diagnostic disagreement of at least 2 out of 9 epiluminescence microscopy observers. The histologic specimens from the 10 lesions were examined by 9 HP observers. The agreement of the HP diagnoses was calculated by means of Fleiss' k statistics. Results The overall HP agreement was less than excellent (k = 0.5). When considering the prevailing epiluminescence microscopic and HP diagnoses, 2 cases were shown to be epiluminescence microscopy false-negative melanomas. Virtually no agreement was found among epiluminescence microscopy observers in 4 cases (40%) or among HP observers in 3 cases (30%). However, only one pigmented skin lesion remained un-classifiable on epiluminescence microscopy as well as HP. Conclusions When at least 2 epiluminescence microscopy experts disagree in the evaluation of a given melanocytic skin lesion, even HP consultations may give equivocal results. The need to establish more reliable epiluminescence microscopic and HP criteria by performing an improved and meticulous clinicopathologic correlation, e.g. by using telecommunication via Internet, is emphasized.