Search

Introduction: Although the dermoscopic features of facial lentiginous melanomas (LM), including lentigo maligna and lentigo maligna melanoma, have been extensively studied, the literature about those located on the scalp is scarce. This study aims to describe the dermoscopic features of scalp LM and assess the diagnostic accuracy of dermoscopy to discriminate them from equivocal benign pigmented macules., Methods: Consecutive cases of scalp LM and histopathology-proven benign but clinically equivocal pigmented macules (actinic keratoses, solar lentigos, seborrhoeic keratoses, and lichen planus-like keratoses) from four referral centres were included. Dermoscopic features were analysed by two blinded experts. The diagnostic performance of a predictive model was assessed., Results: 56 LM and 44 controls were included. Multiple features previously described for facial and extrafacial LM were frequently identified in both groups. Expert's sensitivity to diagnose scalp LM was 76.8% (63.6-87.0) and 78.6% (65.6-88.4), with specificity of 54.5% (38.9-69.6) and 56.8% (41.0-71.7), and fair agreement (kappa coefficient 0.248). The strongest independent predictors of malignancy were (OR, 95% CI) chaos of colour (15.43, 1.48-160.3), pigmented reticular lines (14.96, 1.68-132.9), increased density of vascular network (3.45, 1.09-10.92), and perifollicular grey circles (2.89, 0.96-8.67). The predictive model achieved 85.7% (73.8-93.6) sensitivity, 61.4% (45.5-75.6) specificity, and 81.5 (73.0-90.0) area under curve to discriminate benign and malignant lesions. A diagnostic flowchart was proposed, which should improve the diagnostic performance of dermoscopy., Conclusion: Both facial and extrafacial dermoscopic patterns can be identified in scalp LM, with considerable overlap with benign pigmented macules, leading to low specificity and interobserver agreement on dermoscopy., (© 2023 S. Karger AG, Basel.)

Competing Interests: Conflicts of interest Richard A Scolyer has received fees for professional services from MetaOptima Technology Inc., F. Hoffmann-La Roche Ltd, Evaxion, Provectus Biopharmaceuticals Australia, Qbiotics, Novartis, Merck Sharp & Dohme, NeraCare, AMGEN Inc., Bristol-Myers Squibb, Myriad Genetics, GlaxoSmithKline. Scott W Menzies has received fees for advisory board participation from MoleMap Australia and Scibase AB. John F Thompson has received honoraria for advisory board participation from BMS Australia, MSD Australia, GSK and Provectus Inc, and travel and conference support from GSK, Provectus Inc and Novartis. Yuan Ni, Caroline G Watts, Christine Madronio, Bruce K Armstrong, Rachael L Morton, Graham J Mann, Anne E Cust, and Serigne N Lo have no conflicts of interest to declare.

Background: Diagnosis of skin cancer requires medical expertise, which is scarce. Mobile phone-powered artificial intelligence (AI) could aid diagnosis, but it is unclear how this technology performs in a clinical scenario. Our primary aim was to test in the clinic whether there was equivalence between AI algorithms and clinicians for the diagnosis and management of pigmented skin lesions., Methods: In this multicentre, prospective, diagnostic, clinical trial, we included specialist and novice clinicians and patients from two tertiary referral centres in Australia and Austria. Specialists had a specialist medical qualification related to diagnosing and managing pigmented skin lesions, whereas novices were dermatology junior doctors or registrars in trainee positions who had experience in examining and managing these lesions. Eligible patients were aged 18-99 years and had a modified Fitzpatrick I-III skin type; those in the diagnostic trial were undergoing routine excision or biopsy of one or more suspicious pigmented skin lesions bigger than 3 mm in the longest diameter, and those in the management trial had baseline total-body photographs taken within 1-4 years. We used two mobile phone-powered AI instruments incorporating a simple optical attachment: a new 7-class AI algorithm and the International Skin Imaging Collaboration (ISIC) AI algorithm, which was previously tested in a large online reader study. The reference standard for excised lesions in the diagnostic trial was histopathological examination; in the management trial, the reference standard was a descending hierarchy based on histopathological examination, comparison of baseline total-body photographs, digital monitoring, and telediagnosis. The main outcome of this study was to compare the accuracy of expert and novice diagnostic and management decisions with the two AI instruments. Possible decisions in the management trial were dismissal, biopsy, or 3-month monitoring. Decisions to monitor were considered equivalent to dismissal (scenario A) or biopsy of malignant lesions (scenario B). The trial was registered at the Australian New Zealand Clinical Trials Registry ACTRN12620000695909 (Universal trial number U1111-1251-8995)., Findings: The diagnostic study included 172 suspicious pigmented lesions (84 malignant) from 124 patients and the management study included 5696 pigmented lesions (18 malignant) from the whole body of 66 high-risk patients. The diagnoses of the 7-class AI algorithm were equivalent to the specialists' diagnoses (absolute accuracy difference 1·2% [95% CI -6·9 to 9·2]) and significantly superior to the novices' ones (21·5% [13·1 to 30·0]). The diagnoses of the ISIC AI algorithm were significantly inferior to the specialists' diagnoses (-11·6% [-20·3 to -3·0]) but significantly superior to the novices' ones (8·7% [-0·5 to 18·0]). The best 7-class management AI was significantly inferior to specialists' management (absolute accuracy difference in correct management decision -0·5% [95% CI -0·7 to -0·2] in scenario A and -0·4% [-0·8 to -0·05] in scenario B). Compared with the novices' management, the 7-class management AI was significantly inferior (-0·4% [-0·6 to -0·2]) in scenario A but significantly superior (0·4% [0·0 to 0·9]) in scenario B., Interpretation: The mobile phone-powered AI technology is simple, practical, and accurate for the diagnosis of suspicious pigmented skin cancer in patients presenting to a specialist setting, although its usage for management decisions requires more careful execution. An AI algorithm that was superior in experimental studies was significantly inferior to specialists in a real-world scenario, suggesting that caution is needed when extrapolating results of experimental studies to clinical practice., Funding: MetaOptima Technology., Competing Interests: Declaration of interests SWM is on the scientific advisory board of SciBase AB, and previously for Kāhu (MoleMap), both of which produce competing diagnostic devices for skin cancer. MM received payment from MetaOptima Technology for doing the trial in Sydney. She has also received payments from MetaOptima Technology (unrelated to and before the trial) as a consultant. SNL's institute has received payment for consultancy services from MetaOptima Technology, unrelated to the trial. WY, JL, and MR are employees of MetaOptima Technology. MR is a board member and equity owner of MetaOptima Technology. PT has received fees for professional services from Silverchair; an unrestricted 1-year postdoctoral grant from MetaOptima Technology (2017); speaker fees from Novartis, Lilly, and FotoFinder; and unrestricted grants from Lilly. He is also on the executive board of the International Dermoscopy Society, is President of the Austrian Dermatopathology Society, and is a coauthor of textbooks on dermatoscopy (published by Facultas) and dermatopathology (published by Springer). PG has received fees for professional services from MetaOptima Technology, unrelated to the trial. She has also received fees from La Roche-Posay and Pierre Fabre, support for attending meetings from La Roche-Posay, and is on the faculty of Melanoma Institute Australia. RAS has received fees for professional services from MetaOptima Technology, F Hoffmann-La Roche, Evaxion Biotech, Provectus Biopharmaceuticals Australia, Qbiotics, Novartis, Merck Sharp & Dohme, NeraCare, Amgen, Bristol Myers Squibb, Myriad Genetics, and GlaxoSmithKline. HHC serves as a medical advisor to Metasense. DC has served as a speaker for AbbVie, Gilead Sciences, ViiV Healthcare, and MSD; has served as an advisory board member for ViiV Healthcare; and has received travel support from AbbVie, MSD, ViiV Healthcare, and Gilead Sciences. MG has received a conference travel grant from Sun Pharmaceutical Industries. GH has been supported by an Avant Foundation Early Career Researcher grant and by National Health and Medical Research Council Centres of Research Excellence funding (1135285). PK has received fees and travel support from Sanofi. JMR has received speakers honoraria from Bristol Myers Squibb, Roche, Amgen, and Novartis, and travel support from Roche, Bristol Myers Squibb, and Sanofi. MS has received consulting fees and travel support from Gilead Sciences, ViiV Healthcare/GSK, and MSD; is on the advisory boards of Gilead Sciences, ViiV Healthcare/GSK, and MSD; and is a board member of the Austrian Sexually Transmitted Disease Society. JT has received speaker fees from Lilly and Novartis, travel support from Almirall and AbbVie, and an unrestricted grant from Lilly. PW has received travel support from Pfizer and Merz Pharma, and fees for a case report from Novartis. WW has received a grant from WWTF; consulting fees from Böhringer Ingelheim, Sanofi Genzyme, Eli Lilly, AbbVie, LEO Pharma, Janssen, and Pfizer. He is a committee member of the Austrian Society of Dermatology and Venerology and is on the advisory boards of Sanofi Genzyme, Böhringer Ingelheim, and Eli Lilly. CZ was a coinvestigator on Sydney Cancer Partners Pilot Study Scheme Grant Procel Study-Perioperative Propranolol and Celexocib in Stage III melanoma. HK has received speaker fees from La Roche-Posay, Novartis, Eli Lilly, Pelpharma, Heine, and FotoFinder; has received equipment to his institution from Heine, FotoFinder, Canfield, and DermaMedical; and has received license fees to his institution from MetaOptima Technology, Heine, and Casi. He is member of the executive board of the International Dermoscopy Society. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Conflicts of interest H.P.S. is a shareholder of MoleMap NZ Limited and e-derm consult GmbH, and undertakes regular teledermatological reporting for both companies. H.P.S. is a medical consultant for Canfield Scientific Inc., MoleMap Australia Pty Ltd, Blaze Bioscience Inc. and a medical advisor for First Derm.

Background: The number of naevi on a person is the strongest risk factor for melanoma; however, naevus counting is highly variable due to lack of consistent methodology and lack of inter-rater agreement. Machine learning has been shown to be a valuable tool for image classification in dermatology., Objectives: To test whether automated, reproducible naevus counts are possible through the combination of convolutional neural networks (CNN) and three-dimensional (3D) total body imaging., Methods: Total body images from a study of naevi in the general population were used for the training (82 subjects, 57,742 lesions) and testing (10 subjects; 4,868 lesions) datasets for the development of a CNN. Lesions were labelled as naevi, or not ("non-naevi"), by a senior dermatologist as the gold standard. Performance of the CNN was assessed using sensitivity, specificity, and Cohen's kappa, and evaluated at the lesion level and person level., Results: Lesion-level analysis comparing the automated counts to the gold standard showed a sensitivity and specificity of 79% (76-83%) and 91% (90-92%), respectively, for lesions ≥2 mm, and 84% (75-91%) and 91% (88-94%) for lesions ≥5 mm. Cohen's kappa was 0.56 (0.53-0.59) indicating moderate agreement for naevi ≥2 mm, and substantial agreement (0.72, 0.63-0.80) for naevi ≥5 mm. For the 10 individuals in the test set, person-level agreement was assessed as categories with 70% agreement between the automated and gold standard counts. Agreement was lower in subjects with numerous seborrhoeic keratoses., Conclusion: Automated naevus counts with reasonable agreement to those of an expert clinician are possible through the combination of 3D total body photography and CNNs. Such an algorithm may provide a faster, reproducible method over the traditional in person total body naevus counts., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Background: Timely diagnosis is the cornerstone of melanoma morbidity and mortality reduction. 2D total body photography and dermoscopy are routinely used to assist with early detection of skin malignancies. Polarized 3D total body photography is a novel technique that enables fast image acquisition of almost the entire skin surface. We aimed to determine the added value of 3D total body photography alongside dermoscopy for monitoring cutaneous lesions., Methods: Lesion images from high-risk individuals were assessed for long-term substantial changes via dermoscopy and 3D total body photography. Three case studies are presented demonstrating how 3D total body photography may enhance lesion analysis alongside traditional dermoscopy., Results: 3D total body photography can assist clinicians by presenting cutaneous lesions in their skin ecosystem, thereby providing additional clinical context and enabling a more holistic assessment to aid dermoscopy interpretation. For lesion cases where previous dermoscopy is unavailable, corresponding 3D images can substitute for baseline dermoscopy. Additionally, 3D total body photography is not susceptible to artificial stretch artefacts., Conclusion: 3D total body photography is valuable alongside dermoscopy for monitoring cutaneous lesions. Furthermore, it is capable of surveilling almost the entire skin surface, including areas not traditionally monitored by sequential imaging., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

Importance: Early melanoma diagnosis is associated with better health outcomes, but there is insufficient evidence that screening, such as having routine skin checks, reduces mortality., Objective: To assess melanoma-specific and all-cause mortality associated with melanomas detected through routine skin checks, incidentally or patient detected. A secondary aim was to examine patient, sociodemographic, and clinicopathologic factors associated with different modes of melanoma detection., Design, Setting, and Participants: This prospective, population-based, cohort study included patients in New South Wales, Australia, who were diagnosed with melanoma over 1 year from October 23, 2006, to October 22, 2007, in the Melanoma Patterns of Care Study and followed up until 2018 (mean [SD] length of follow-up, 11.9 [0.3] years) by using linked mortality and cancer registry data. All patients who had invasive melanomas recorded at the cancer registry were eligible for the study, but the number of in situ melanomas was capped. The treating doctors recorded details of melanoma detection and patient and clinical characteristics in a baseline questionnaire. Histopathologic variables were obtained from pathology reports. Of 3932 recorded melanomas, data were available and analyzed for 2452 (62%; 1 per patient) with primary in situ (n = 291) or invasive (n = 2161) cutaneous melanoma. Data were analyzed from March 2020 to January 2021., Main Outcomes and Measures: Melanoma-specific mortality and all-cause mortality., Results: A total of 2452 patients were included in the analyses. The median age at diagnosis was 65 years (range, 16-98 years), and 1502 patients (61%) were men. A total of 858 patients (35%) had their melanoma detected during a routine skin check, 1148 (47%) self-detected their melanoma, 293 (12%) had their melanoma discovered incidentally when checking another skin lesion, and 153 (6%) reported "other" presentation. Routine skin-check detection of invasive melanomas was associated with 59% lower melanoma-specific mortality (subhazard ratio, 0.41; 95% CI, 0.28-0.60; P < .001) and 36% lower all-cause mortality (hazard ratio, 0.64; 95% CI, 0.54-0.76; P < .001), adjusted for age and sex, compared with patient-detected melanomas. After adjusting for prognostic factors including ulceration and mitotic rate, the associations were 0.68 (95% CI, 0.44-1.03; P = .13), and 0.75 (95% CI, 0.63-0.90; P = .006), respectively. Factors associated with higher odds of routine skin-check melanoma detection included being male (female vs male, odds ratio [OR], 0.73; 95% CI, 0.60-0.89; P = .003), having previous melanoma (vs none, OR, 2.36; 95% CI, 1.77-3.15; P < .001), having many moles (vs not, OR, 1.39; 95% CI, 1.10-1.77; P = .02), being 50 years or older (eg, 50-59 years vs <40 years, OR, 2.89; 95% CI, 1.92-4.34; P < .001), and living in nonremote areas (eg, remote or very remote vs major cities, OR, 0.23; 95% CI, 0.05-1.04; P = .003)., Conclusions and Relevance: In this cohort study, melanomas diagnosed through routine skin checks were associated with significantly lower all-cause mortality, but not melanoma-specific mortality, after adjustment for patient, sociodemographic, and clinicopathologic factors.

Importance: A previous single-center study observed fewer excisions, lower health care costs, thinner melanomas, and better quality of life when surveillance of high-risk patients was conducted in a melanoma dermatology clinic with a structured surveillance protocol involving full-body examinations every 6 months aided by total-body photography (TBP) and sequential digital dermoscopy imaging (SDDI)., Objective: To examine longer-term sustainability and expansion of the surveillance program to numerous practices, including a primary care skin cancer clinic setting., Design, Setting, and Participants: This prospective cohort study recruited 593 participants assessed from 2012 to 2018 as having very high risk of melanoma, with a median of 2.9 years of follow-up (interquartile range, 1.9-3.3 years), from 4 melanoma high-risk clinics (3 dermatology clinics and 1 primary care skin cancer clinic) in New South Wales, Australia. Data analyses were conducted from February to September 2020., Exposures: Six-month full-body examination with the aid of TBP and SDDI. For equivocal lesions, the clinician performed SDDI at 3 or 6 months., Main Outcomes and Measures: All suspect monitored or excised lesions were recorded, and pathology reports obtained. Outcomes included the incidence and characteristics of new lesions and the association of diagnostic aids with rates of new melanoma detection., Results: Among 593 participants, 340 (57.3%) were men, and the median age at baseline was 58 years (interquartile range, 47-66 years). There were 1513 lesions excised during follow-up, including 171 primary melanomas. The overall benign to malignant excision ratio, including keratinocyte carcinomas, was 0.8:1.0; the benign melanocytic to melanoma excision ratio was 2.4:1.0; and the melanoma in situ to invasive melanoma ratio was 2.2:1.0. The excision ratios were similar across the 4 centers. The risk of developing a new melanoma was 9.0% annually in the first 2 years and increased with time, particularly for those with multiple primary melanomas. The thicker melanomas (>1-mm Breslow thickness; 7 of 171 melanomas [4.1%]) were mostly desmoplastic or nodular (4 of 7), self-detected (2 of 7), or clinician detected without the aid of TBP (3 of 7). Overall, new melanomas were most likely to be detected by a clinician with the aid of TBP (54 of 171 [31.6%]) followed by digital dermoscopy monitoring (50 of 171 [29.2%])., Conclusions and Relevance: The structured surveillance program for high-risk patients may be implemented at a larger scale given the present cohort study findings suggesting the sustainability and replication of results in numerous settings, including a primary care skin cancer clinic.

Short-term monitoring of lesion changes has been a widely accepted clinical guideline for melanoma screening. When there is a significant change of a melanocytic lesion at three months, the lesion will be excised to exclude melanoma. However, the decision on change or no-change heavily depends on the experience and bias of individual clinicians, which is subjective. For the first time, a novel deep learning based method is developed in this paper for automatically detecting short-term lesion changes in melanoma screening. The lesion change detection is formulated as a task measuring the similarity between two dermoscopy images taken for a lesion in a short time-frame, and a novel Siamese structure based deep network is proposed to produce the decision: changed (i.e. not similar) or unchanged (i.e. similar enough). Under the Siamese framework, a novel structure, namely Tensorial Regression Process, is proposed to extract the global features of lesion images, in addition to deep convolutional features. In order to mimic the decision-making process of clinicians who often focus more on regions with specific patterns when comparing a pair of lesion images, a segmentation loss (SegLoss) is further devised and incorporated into the proposed network as a regularization term. To evaluate the proposed method, an in-house dataset with 1,000 pairs of lesion images taken in a short time-frame at a clinical melanoma centre was established. Experimental results on this first-of-a-kind large dataset indicate that the proposed model is promising in detecting the short-term lesion change for objective melanoma screening.

Background: Scalp melanomas are usually thicker and show worse prognosis than other sites and other head and neck melanomas. One hypothesis to explain this aggressive behavior could be diagnosis delay attributed to hair concealment of lesions., Methods: Primary melanomas of the scalp diagnosed over two decades at four reference centers in Australia and Italy were included. Hair coverage and visibility of the lesions were assessed on preoperative photographic documentation by two investigators and correlated with some prognostic factors (Breslow thickness, mitotic rate, and ulceration). Patients records and pathology reports provided clinical and histological data., Results: The majority of 113 melanomas included were located on easily visible areas of the scalp - hairless scalp (49%) or hairline (15%). The remaining ones (36%), considered to be hair-covered, showed more frequently thinning of hair (63%) than a dense hair coverage (37%). Melanomas of "hairy scalps" were more frequently invasive (81%) and had higher median Breslow (0.8 ± 1.3 mm) than those arising on bald scalps or areas with thinning of hair (43%; 0 ± 0.6 mm), P = 0.004. However, when considering only the invasive cases (n = 55), Breslow thickness and mitotic rate were not statistically different between concealed and easily visible areas. Melanomas detected by a doctor were thinner than those first noticed by the patient, relatives, or a hairdresser (P < 0.001)., Conclusions: Most scalp melanomas arose on easily visible areas, which are more prone to ultraviolet damage. Hair-covered ones, despite rare, could be overlooked during examination. Proactive screening of the scalp area should be encouraged., (© 2020 the International Society of Dermatology.)

Little is known about the risk of progression of lentigo maligna to lentigo maligna melanoma. We determine the annual risk of progression of lentigo maligna to lentigo maligna melanoma by analysing a prospective population-based survey of recently diagnosed anterior (visible in a mirror) head and neck lentigo malignas and lentigo maligna melanomas. Six hundred eighty-two consecutive patients aged 18-80 years with non-recurrent lentigo maligna or lentigo maligna melanoma, diagnosed between 1 July 2015 and 20 April 2016, were identified from pathology notifications to the New South Wales Cancer Registry (Australia) and sent survey questionnaires soon after diagnosis (median 4.6 months interquartile range: 3.8-5.7). Details of the time the lesion was present and when changes to it were noticed before diagnostic biopsy were ascertained by surveying the patients, of whom 53.5% agreed to participate. There was little difference between the proportions of lentigo maligna melanoma and lentigo maligna in the consenting and non-consenting patients (P = 0.56). Two hundred twenty-eight lentigo maligna (median age 67 years, range: 38-80) and 33 lentigo maligna melanoma (70 years, 43-80) were surveyed. There was no difference between the time lentigo maligna melanoma was present on the skin (median 18 months, range: 0-690) and the time lentigo maligna was (18 months, 0-665) (P = 0.972). The estimated risk of progression of lentigo maligna to lentigo maligna melanoma was 3.5% per year (95% confidence interval: 2.5-5.0). This equates to an average time for lentigo maligna to progress to lentigo maligna melanoma of 28.3 years (95% confidence interval: 20.0-40.5) in this population. Although our data suggests that the annual progression rate of lentigo maligna is more than 25 times greater than previously suggested, the rate is still low.

Objective: This study aimed to evaluate the cost effectiveness of a newly developed psycho-educational intervention to reduce fear of cancer recurrence (FCR) in early-stage melanoma patients., Methods: A within-trial cost-effectiveness and cost-utility analysis was conducted from the Australian health system perspective using data from linked Medicare records. Outcomes included FCR, measured with the severity subscale of the FCR Inventory; quality-adjusted life years (QALYs) measured using the preference-based instrument, Assessment of Quality of Life-8 Dimensions (AQoL-8D) and 12-month survival. An incremental cost-effectiveness ratio (ICER) was calculated for two economic outcomes: (1) cost per additional case of 'high' FCR avoided and (2) cost per QALY gained. Means and 95% CIs around the ICER were generated from non-parametric bootstrapping with 1000 replications., Results: A total of 151 trial participants were included in the economic evaluation. The mean cost of the psycho-educational intervention was AU$1614 per participant, including intervention development costs. The ICER per case of high FCR avoided was AU$12,903. The cost-effectiveness acceptability curve demonstrated a 78% probability of the intervention being cost effective relative to the control at a threshold of AU$50,000 per extra person avoiding FCR. The ICER per QALY gained was AU$116,126 and the probability of the intervention being cost effective for this outcome was 36% at a willingness to pay of AU$50,000 per QALY., Conclusion: The psycho-educational intervention reduced FCR at 12 months for people at high risk of developing another melanoma and may represent good value for money. For the QALY outcome, the psycho-educational intervention is unlikely to be cost effective at standard government willingness-to-pay levels. The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (CTRN12613000304730).

Background/objectives: There are limited population-based data documenting the incidence and management of lentigo maligna (LM) and invasive lentigo maligna melanoma (LMM). We report the data on occurrence and management of LM and LMM in an Australian population., Methods: Prospective collection of incidence and clinician-reported management of melanoma in situ (MIS; n = 450, capped) and localised invasive melanoma (n = 3251) notified to the New South Wales Cancer Registry over 12-months in 2006-2007., Results: The estimated annual incidence of all MIS was 27.0 per 100 000 (LM 12.2, non-LM MIS 5.9 and unclassified MIS 9.0). Patients with LM or LMM were on average approximately 10 years older than those with other melanoma subtypes (P < 0.001). The head and neck was the location of 59% of LM, 44% of LMM and <20% of other melanoma subtypes (P < 0.001). The majority of LM and LMM were treated only by specialists. Diagnostic partial biopsies were more frequent for LM and LMM than for other melanoma subtypes, and primary care physicians were more likely than specialists to do a punch partial biopsy than a shave biopsy. The reported median definitive excision margin for LM was 5.0 mm compared with 7.2 mm for non-LM MIS (P = 0.001)., Conclusions: In this Australian population, LM was twice as frequent as other types of MIS. Improved strategies for diagnosis and management are required., (© 2018 The Australasian College of Dermatologists.)

Background/objectives: Patients on biologic therapy are thought to be at increased risk of developing non-melanoma skin cancers and melanomas. It is unknown whether biologic therapy alters the natural history of melanocytic naevi. Therefore, a prospective observational study was conducted to determine whether psoriasis patients on biologic therapy develop changes in naevi., Methods: Clinical and dermoscopic assessment of all melanocytic naevi was performed in 45 psoriasis patients on biologic therapy versus a control cohort of 43 subjects, using sequential digital dermoscopic imaging and total body photography. The mean follow-up period was 1.5 years., Results: The study and control patients had comparable age, gender, previous and family history of non-melanoma skin cancers and melanomas, as well as previous sun exposure and total number of naevi. The number of naevi with major dermoscopic changes was 3% in the study and 1.9% in the control group, with an adjusted incidence rate ratio of 1.45 (95% confidence interval 0.90-2.33; P = 0.125). The rate of minor changes was 15.9% in the study group versus 19.4% in the control (adjusted incidence rate ratio 0.77, 95% confidence interval 0.57-1.08; P = 0.14). There were six new dysplastic naevi in 4/45 biologic patients and four in 4/43 controls; however, the difference was not significant (relative risk 0.96, 95% confidence interval -0.12 to 0.12; P = 0.95). There were no melanomas in either group., Conclusion: Over a mean follow-up period of 1.5 years there was no evidence of significantly different changes in naevi or development of new dysplastic naevi in psoriasis patients on biologic treatment compared to controls., (© 2018 The Australasian College of Dermatologists.)

Introduction: The evidence-based national clinical practice guidelines for the management of cutaneous melanoma published in 2008 are currently being updated. This article summarises the findings from multiple chapters of the guidelines on different methods of melanoma detection and of monitoring the skin for patients at high risk of melanoma. Early detection of melanoma is critical, as thinner tumours are associated with enhanced survival; therefore, strategies to improve early detection are important to reduce melanoma-related mortality., Main Recommendations: Clinicians who perform skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy. The use of short term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual melanocytic lesions of concern. The use of long term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual or multiple melanocytic lesions for routine surveillance of high risk patients. The use of total body photography should be considered in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi. There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma., Management Overview: Determining the relative indications for each diagnostic method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach., (© 2018 AMPCo Pty Ltd.)

Importance: The diagnosis of a life-threatening disease like melanoma can affect all aspects of a person's life, including health-related quality of life (HRQOL) and psychological aspects of melanoma such as fear of cancer recurrence (FCR). Economic evaluations of psychological interventions require preference-based (utility) instruments that are sensitive to changes in well-being and HRQOL; however, very few studies have evaluated the sensitivity of these instruments when used for people with melanoma., Objective: To compare utility scores from the multiple-attribute instrument Assessment of Quality of Life-8-Dimension Scale (AQoL-8D) with the mapped utility scores of the Functional Assessment of Cancer Therapy-Melanoma (FACT-M) and to investigate the sensitivity of both instruments in identifying the influence of FCR on HRQOL., Design, Setting, and Participants: This assessment of data from a randomized clinical trial of a psychoeducational intervention to reduce FCR, conducted at 3 high-risk melanoma clinics in Australia, evaluated 164 patients with early-stage melanoma and a high risk of developing a second primary melanoma., Main Outcomes and Measures: The FACT-M and AQoL-8D were used to assess HRQOL and FCR among the study participants. Concurrent validity was assessed by comparing the total and subdomain scores of the 2 instruments, and the strength of associations was assessed using Pearson correlation coefficient. Convergent validity was assessed by comparing participants' HRQOL, demographic, and clinical characteristics using the χ2 test and F statistic. Both the FACT-M and AQoL-8D utilities were regressed on FCR Inventory (FCRI) severity scores to estimate the effect of elevated FCR on HRQOL., Results: A total of 164 participants completed the baseline questionnaires, but only 163 met all inclusion criteria and underwent the full analysis: 72 were women; 91 were men; and mean (SD) age was 58.2 (12.1) years. Both the AQoL-8D and FACT-M instruments showed good concurrent validity and could differentiate between relevant subgroups including level of FCRI severity. The AQoL-8D and FACT-M utilities were strongly correlated (r2 = 0.57). Respondents had a mean (SD) AQoL-8D utility of 0.77 (0.2), and a mean (SD) FACT-M utility score of 0.76 (0.07). High levels of FCRI severity were associated with a decrease in utility of 0.12 (95% CI, -0.19 to -0.05) as measured by AQoL-8D, and a decrease of 0.03 (95% CI, -0.05 to -0.01) as measured by the FACT-M., Conclusions and Relevance: For economic evaluations of psychological interventions in melanoma, the AQoL-8D and FACT-M are valid measures of utility; however, the AQoL-8D demonstrates greater sensitivity to FCRI severity. Our results suggest a significant association between FCR and HRQOL.

Aims: Early recognition and accurate diagnosis underpins melanoma survival. Identifying early melanomas arising in association with pre-existing lesions is often challenging. Clinically suspicious foci, however small, must be identified and examined histologically. This study assessed the accuracy of punch biopsy 'scoring' of suspicious foci in excised atypical pigmented skin lesions to identify early melanomas., Methods and Results: Forty-one excised pigmented skin lesions with a clinically/dermoscopically focal area of concern for melanoma, with the suspicious focus marked prior to excision with a punch biopsy 'score' (a partial incision into the skin surface), were analysed. Melanoma was diagnosed in nine of 41 cases (22%). In eight of nine cases (89%) the melanoma was associated with a naevus, and in seven of nine (88%) cases the melanoma was identified preferentially by the scored focus. In six of nine cases (67%), the melanoma was entirely encompassed by the scored focus. In one case of melanoma in situ, the diagnostic material was identified only on further levelling through the scored focus. In 28 of 32 of non-melanoma cases (88%), the scored focus identified either diagnostic features of a particular lesion or pathological features that correlated with the clinical impression of change/atypia including altered architecture or distribution of pigmentation, features of irritation or regression., Conclusions: The 'punch scoring technique' allows direct clinicopathological correlation and facilitates early melanoma diagnosis by focusing attention on clinically suspicious areas. Furthermore, it does not require special expertise in ex-vivo clinical techniques for implementation. Nevertheless, in some cases examination of the lesion beyond the scored focus is also necessary to make a diagnosis of melanoma., (© 2017 John Wiley & Sons Ltd.)

Background: Nonpigmented skin cancer is common, and diagnosis with the unaided eye is error prone., Objective: To investigate whether dermatoscopy improves the diagnostic accuracy for nonpigmented (amelanotic) cutaneous neoplasms., Methods: We collected a sample of 2072 benign and malignant neoplastic lesions and inflammatory conditions and presented close-up images taken with and without dermatoscopy to 95 examiners with different levels of experience., Results: The area under the curve was significantly higher with than without dermatoscopy (0.68 vs 0.64, P < .001). Among 51 possible diagnoses, the correct diagnosis was selected in 33.1% of cases with and 26.4% of cases without dermatoscopy (P < .001). For experts, the frequencies of correct specific diagnoses of a malignant lesion improved from 40.2% without to 51.3% with dermatoscopy. For all malignant neoplasms combined, the frequencies of appropriate management strategies increased from 78.1% without to 82.5% with dermatoscopy., Limitations: The study deviated from a real-life clinical setting and was potentially affected by verification and selection bias., Conclusions: Dermatoscopy improves the diagnosis and management of nonpigmented skin cancer and should be used as an adjunct to examination with the unaided eye., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background/objectives: To describe the method of diagnosis, clinical management and adherence to clinical practice guidelines for melanoma patients at high risk of a subsequent primary melanoma, and compare this with melanoma patients at lower risk., Methods: The Melanoma Patterns of Care study was a population-based, observational study based on doctors' reported clinical management of melanoma patients in New South Wales, Australia, diagnosed with in situ or invasive melanoma over a 12-month period from October 2006. Of 2605 patients with localised melanoma, 1019 (39%) were defined as at higher risk due to the presence of one or more of the following factors: a family history of melanoma (11%), multiple primary melanomas (17%), or many naevi (24%)., Results: Compared to patients at lower risk, high risk patients were more likely to receive their initial care from a primary care physician (56% vs 50%, P = 0.002), have their melanoma detected during a routine skin check (40% vs 33%, P < 0.001), have their lesion assessed with dermoscopy (63% vs 56%, P = 0.002), and be encouraged to have skin surveillance (84% vs 77%, P < 0.001) and skin self-examination (87% vs 83%, P = 0.03). Higher socioeconomic status and urban residence were associated with patients at higher risk receiving initial treatment from a specialist doctor., Conclusions: Clinical management of higher risk patients was more likely to conform to clinical practice guidelines for diagnosis and skin surveillance than to melanoma patients at lower risk., (© 2016 The Australasian College of Dermatologists.)

Purpose Clinical guidelines recommend that people at high risk of melanoma receive regular surveillance to improve survival through early detection. A specialized High Risk Clinic in Sydney, Australia was found to be effective for this purpose; however, wider implementation of this clinical service requires evidence of cost-effectiveness and data addressing potential overtreatment of suspicious skin lesions. Patients and Methods A decision-analytic model was built to compare the costs and benefits of specialized surveillance compared with standard care over a 10-year period, from a health system perspective. A high-risk standard care cohort was obtained using linked population data, comprising the Sax Institute's 45 and Up cohort study, linked to Medicare Benefits Schedule claims data, the cancer registry, and hospital admissions data. Benefits were measured in quality-adjusted life-years gained. Sensitivity analyses were undertaken for all model parameters. Results Specialized surveillance through the High Risk Clinic was both less expensive and more effective than standard care. The mean saving was A$6,828 (95% CI, $5,564 to $8,092) per patient, and the mean quality-adjusted life-year gain was 0.31 (95% CI, 0.27 to 0.35). The main drivers of the differences were detection of melanoma at an earlier stage resulting in less extensive treatment and a lower annual mean excision rate for suspicious lesions in specialized surveillance (0.81; 95% CI, 0.72 to 0.91) compared with standard care (2.55; 95% CI, 2.34 to 2.76). The results were robust when tested in sensitivity analyses. Conclusion Specialized surveillance was a cost-effective strategy for the management of individuals at high risk of melanoma. There were also fewer invasive procedures in specialized surveillance compared with standard care in the community.

Importance: The identification of a subgroup at higher risk of melanoma may assist in early diagnosis., Objective: To characterize melanoma patients and the clinical features associated with their melanomas according to patient risk factors: many nevi, history of previous melanoma, and family history of melanoma, to assist with improving the identification and treatment of a higher-risk subgroup., Design, Setting, and Participants: The Melanoma Patterns of Care study was a population-based observational study of physicians' reported treatment of 2727 patients diagnosed with an in situ or invasive primary melanoma over a 12-month period from October 2006 to 2007 conducted in New South Wales. Our analysis of these data took place from 2015 to 2016., Main Outcomes and Measures: Age at diagnosis and body site of melanoma., Results: Of the 2727 patients with melanoma included, 1052 (39%) were defined as higher risk owing to a family history of melanoma, multiple primary melanomas, or many nevi. Compared with patients with melanoma who were at lower risk (ie, without any of these risk factors), the higher-risk group had a younger mean age at diagnosis (62 vs 65 years, P < .001), but this differed by risk factor (56 years for patients with a family history, 59 years for those with many nevi, and 69 years for those with a previous melanoma). These age differences were consistent across all body sites. Among higher-risk patients, those with many nevi were more likely to have melanoma on the trunk (41% vs 29%, P < .001), those with a family history of melanoma were more likely to have melanomas on the limbs (57% vs 42%, P < .001), and those with a personal history were more likely to have melanoma on the head and neck (21% vs 15%, P = .003)., Conclusions and Relevance: These findings suggest that a person's risk factor status could be used to tailor surveillance programs and education about skin self-examination.

Importance: The comparative diagnostic performance of dermoscopic algorithms and their individual criteria are not well studied., Objectives: To analyze the discriminatory power and reliability of dermoscopic criteria used in melanoma detection and compare the diagnostic accuracy of existing algorithms., Design, Setting, and Participants: This was a retrospective, observational study of 477 lesions (119 melanomas [24.9%] and 358 nevi [75.1%]), which were divided into 12 image sets that consisted of 39 or 40 images per set. A link on the International Dermoscopy Society website from January 1, 2011, through December 31, 2011, directed participants to the study website. Data analysis was performed from June 1, 2013, through May 31, 2015. Participants included physicians, residents, and medical students, and there were no specialty-type or experience-level restrictions. Participants were randomly assigned to evaluate 1 of the 12 image sets., Main Outcomes and Measures: Associations with melanoma and intraclass correlation coefficients (ICCs) were evaluated for the presence of dermoscopic criteria. Diagnostic accuracy measures were estimated for the following algorithms: the ABCD rule, the Menzies method, the 7-point checklist, the 3-point checklist, chaos and clues, and CASH (color, architecture, symmetry, and homogeneity)., Results: A total of 240 participants registered, and 103 (42.9%) evaluated all images. The 110 participants (45.8%) who evaluated fewer than 20 lesions were excluded, resulting in data from 130 participants (54.2%), 121 (93.1%) of whom were regular dermoscopy users. Criteria associated with melanoma included marked architectural disorder (odds ratio [OR], 6.6; 95% CI, 5.6-7.8), pattern asymmetry (OR, 4.9; 95% CI, 4.1-5.8), nonorganized pattern (OR, 3.3; 95% CI, 2.9-3.7), border score of 6 (OR, 3.3; 95% CI, 2.5-4.3), and contour asymmetry (OR, 3.2; 95% CI, 2.7-3.7) (P < .001 for all). Most dermoscopic criteria had poor to fair interobserver agreement. Criteria that reached moderate levels of agreement included comma vessels (ICC, 0.44; 95% CI, 0.40-0.49), absence of vessels (ICC, 0.46; 95% CI, 0.42-0.51), dark brown color (ICC, 0.40; 95% CI, 0.35-0.44), and architectural disorder (ICC, 0.43; 95% CI, 0.39-0.48). The Menzies method had the highest sensitivity for melanoma diagnosis (95.1%) but the lowest specificity (24.8%) compared with any other method (P < .001). The ABCD rule had the highest specificity (59.4%). All methods had similar areas under the receiver operating characteristic curves., Conclusions and Relevance: Important dermoscopic criteria for melanoma recognition were revalidated by participants with varied experience. Six algorithms tested had similar but modest levels of diagnostic accuracy, and the interobserver agreement of most individual criteria was poor.

Importance: The clinical phenotype and certain predisposing genetic mutations that confer increased melanoma risk are established; however, no consensus exists regarding optimal screening for such individuals. Early identification remains the most important intervention in reducing melanoma mortality., Objective: To evaluate the impact of full-body examinations every 6 months supported by dermoscopy and total-body photography (TBP) on all patients and sequential digital dermoscopy imaging (SDDI), when indicated, on detecting primary melanoma in an extreme-risk population., Design, Setting, and Participants: Prospective observational study from February 2006 to February 2011, with patients recruited from Sydney Melanoma Diagnostic Centre and Melanoma Institute Australia who had a history of invasive melanoma and dysplastic nevus syndrome, history of invasive melanoma and at least 3 first-degree or second-degree relatives with prior melanoma, history of at least 2 primary invasive melanomas, or a CDKN2A or CDK4 gene mutation., Exposures: Six-month full-body examination compared with TBP. For equivocal lesions, SDDI short term (approximately 3 months) or long term (≥6 months), following established criteria, was performed. Atypical lesions were excised., Main Outcomes and Measures: New primary melanoma numbers, characteristics, and cumulative incidence in each patient subgroup; effect of diagnostic aids on new melanoma identification., Results: In 311 patients with a median (interquartile range [IQR]) follow-up of 3.5 (2.4-4.2) years, 75 primary melanomas were detected, 14 at baseline visit. Median (IQR) Breslow thickness of postbaseline incident melanomas was in situ (in situ to 0.60 mm). Thirty-eight percent were detected using TBP and 39% with SDDI. Five melanomas were greater than 1 mm Breslow thickness, 3 of which were histologically desmoplastic; the other 2 had nodular components. The benign to malignant excision ratio was 1.6:1 for all lesions excised and 4.4:1 for melanocytic lesions. Cumulative risk of developing a novel primary melanoma was 12.7% by year 2, with new primary melanoma incidence during the final 3 years of follow-up half of that observed during the first 2 years (incidence density ratio, 0.43 [95% CI, 0.25-0.74]; P = .002)., Conclusions and Relevance: Monitoring patients at extreme risk with TBP and SDDI assisted with early diagnosis of primary melanoma. Hypervigilance for difficult-to-detect thick melanoma subtypes is crucial.

Dermoscopy has been shown in meta-analyses to improve the diagnostic accuracy of melanoma unequivocally compared with naked eye examination and to reduce excision rates of benign melanocytic lesions in clinical trials. Sequential digital dermoscopy imaging (SDDI) allows the detection of dermoscopic featureless melanoma. When used in high-risk individuals or on individual suspicious melanocytic lesions, it has a gross impact for detecting melanoma in clinical practice, with a range of 34% to 61% of melanomas detected exclusively using SDDI in these patients. Furthermore, SDDI has been shown to reduce the excision of benign lesions when used in combination with dermoscopy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Importance: Lentigo maligna (LM) is a clinical, pathologic, and therapeutic challenge with a higher risk of local recurrence than other types of melanoma correctly treated and also carries the cosmetically sensitive localization of head and neck., Objective: To determine whether in vivo reflectance confocal microscopy (RCM) mapping of difficult LM cases might alter patient care and management., Design: Analysis of LM and LM melanoma (LMM) in a series of patients with large facial lesions requiring complex reconstructive surgery and/or recurrent or poorly delineated lesions at any body sites were investigated., Settings: Two tertiary referral melanoma centers in Sydney, Australia., Participants: Thirty-seven patients with LM (including 5 with LMM) were mapped with RCM. Fifteen patients had a recurrent LM, including 9 with multiple prior recurrences. The LM was classified amelanotic in 10 patients, lightly pigmented in 9, and partially pigmented in 18., Interventions: The RCM images were obtained in 4 radial directions (allowing for anatomic barriers) for LM margin delineation using an RCM LM score previously described by our research team., Main Outcome Measures: Differences in the margin of LM as determined by RCM vs dermoscopy vs histopathologic analysis., Results: Seventeen of 29 patients (59%) with dermoscopically visible lesions had subclinical (RCM-identified) disease evident more than 5 mm beyond the dermoscopy margin (ie, beyond the excision margin recommended in published guidelines). The RCM mapping changed the management in 27 patients (73%): 11 patients had a major change in their surgical procedure, and 16 were offered radiotherapy or imiquimod treatment as a consequence of the RCM findings. Treatment was surgical in 17 of 37 patients. Surgical excision margins (based on the RCM mapping) were histopathologically involved in only 2 patients, each of whom had an LM lesion larger than 6 cm., Conclusions and Relevance: In vivo RCM can provide valuable information facilitating optimal patient care management.

Importance: Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical., Objective: To determine the dermoscopy features of NM., Design: Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes., Setting: Predominantly hospital-based clinics from 5 continents., Main Outcome Measures: Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma., Results: Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM., Conclusions and Relevance: When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

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., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Objective: To describe and analyze the clinical and dermoscopic characteristics of desmoplastic melanoma (DM) as a function of pathologic subtype and phenotypic traits., Design: Retrospective case series., Setting: Eight high-risk dermatology clinics., Patients: Patients with DM confirmed by histopathologic analysis whose records included a high-quality dermoscopic image., Main Outcome Measures: Clinical, dermoscopic, and histopathologic features of DM., Results: A total of 37 DM cases were identified. The majority of patients had fair skin, few nevi, and no history of melanoma. Lentigo maligna was the most frequent subtype of melanoma associated with DM. The most frequent clinical presentation of DM was a palpable and/or indurated lesion located on sun-exposed skin. Forty-three percent of cases were classified as pure DM, and 57% as mixed DM. Pure DM lesions were thicker than mixed DM lesions (4.10 vs 2.83 mm) (P = .22) and were less likely to have an associated epidermal non-DM component (63% vs 100%) (P = .004). Dermoscopically, DMs had at least 1 melanoma-specific structure, the most frequent being atypical vascular structures. Peppering was more frequently seen in pure DM (44% in pure DM vs 24% in mixed DM) (P = .29). In contrast, crystalline structures, polymorphous vessels, and vascular blush were more commonly seen in mixed DM., Conclusions: Though DM can be difficult to diagnose based on clinical morphologic characteristics alone, dermoscopy has proved to be a useful aid during the evaluation of clinically equivocal lesions or those lesions with a benign appearance. The most common dermoscopic clues observed in DMs included atypical vascular structures, peppering, and occasionally other melanoma-specific structures.

Background: There is limited evidence on the relative effectiveness of different follow-up schedules for patients with AJCC stage I or II melanoma, but less frequent follow-up than is currently recommended has been proposed., Objectives: To describe melanoma clinicians' perspectives on the functions of follow-up, factors that influence follow-up intervals, and important considerations for extending intervals., Methods: Qualitative interviews with 16 clinicians (surgical oncologists, dermatologists, melanoma unit physicians) who conduct follow-up at two of Australia's largest specialist centers., Results: Follow-up is conducted for early detection of recurrences or new primary melanomas, to manage patient anxiety, support patient self-care, and as part of shared care. Recommended intervals are based on guidelines but account for each patient's clinical risk profile, level of anxiety, patient education requirements, capacity to engage in skin self-examination, and how the clinician prefers to manage any suspicious lesions., Conclusions: To revise guidelines and implement change it is important to understand the rationale underpinning existing practice. Extended follow-up intervals for early stage melanoma are more likely to be adopted after the first year when patients are less anxious and sufficiently prepared to conduct self-examination. Clinicians may retain existing schedules for highly anxious patients or those unable to examine themselves., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Patients with early stage melanoma have high survival rates but require long-term follow-up to detect recurrences and/or new primary tumours. Shared care between melanoma specialists and general practitioners is an increasingly important approach to meeting the needs of a growing population of melanoma survivors., Methods: In-depth qualitative study based on semi-structured interviews with 16 clinicians (surgical oncologists, dermatologists and melanoma unit GPs) who conduct post-treatment follow-up at two of Australia's largest specialist referral melanoma treatment and diagnosis units. Interviews were recorded, transcribed and analysed to identify approaches to shared care in follow-up, variations in practice, and explanations of these., Results: Melanoma unit clinicians utilised shared care in the follow-up of patients with early stage melanoma. Schedules were determined by patients' clinical risk profiles. Final arrangements for delivery of those schedules (by whom and where) were influenced by additional psychosocial, professional and organizational considerations. Four models of shared care were described: (a) surgical oncologist alternating with dermatologist (in-house or local to patient); (b) melanoma unit dermatologist and other local doctor (e.g. family physician); (c) surgical oncologist and local doctor; or (d) melanoma physician and local doctor., Conclusions: These models of shared care offer alternative solutions to managing the requirements for long-term follow-up of a growing number of patients with stage I/II melanoma, and warrant further comparative evaluation of outcomes in clinical trials, with detailed cost/benefit analyses.

We describe two algorithms to diagnose basal cell carcinomas (BCCs) and melanomas (MMs) using in vivo reflectance confocal microscopy (RCM). A total of 710 consecutive cutaneous lesions excised to exclude malignancy (216 MMs, 266 nevi, 119 BCCs, 67 pigmented facial macules, and 42 other skin tumors) were imaged by RCM. RCM features were correlated with pathology diagnosis to develop diagnostic algorithms. The diagnostic accuracy of the BCC algorithm defined on multivariate analysis of the training set (50%) and tested on the remaining cases was 100% sensitivity, 88.5% specificity. Positive features were polarized elongated features, telangiectasia and convoluted vessels, basaloid nodules, and epidermal shadowing corresponding to horizontal clefting. Negative features were non-visible papillae, disarrangement of the epidermal layer, and cerebriform nests. Multivariate discriminant analysis on the training set (excluding the BCCs) identified seven independently significant features for MM diagnosis. The diagnostic accuracy of the MM algorithm on the test set was 87.6% sensitivity, 70.8% specificity. The four invasive MMs that were misdiagnosed by RCM were all of nevoid subtype. RCM is a highly accurate non-invasive technique for BCC diagnosis. Good diagnostic accuracy was achieved also for MM diagnosis, although rare variants of melanocytic tumors may limit the strict application of the algorithm.

In this article, we will summarize some of the highlights of the third annual conference on skin cancer, with special emphasis on the the recent advances regarding melanoma and non-melanoma skin cancer epidemiology, diagnosis and treatment. Topics were particularly addressed to a newly developing medical branch in Australia, namely that of Primary Care Skin Cancer Practitioners, and focused on strategies to improve primary and secondary prevention and early detection of melanoma and non-melanoma skin cancer using dermoscopy. Controversies related to skin cancer screening programs and recent progresses for treating advanced melanoma were additionally discussed. Yet, besides its scientific goals, the conference aimed also to encourage research originating in primary care and relevant to primary care.

Objective: To determine whether certain patient demographics are associated with poorer specificity for the diagnosis of melanoma in nevi undergoing short-term sequential digital dermoscopic imaging., Design: Retrospective cohort study performed from April 1, 1998, through May 31, 2007., Setting: Sydney Melanoma Diagnostic Centre, a tertiary referral institution., Patients: A total of 2497 benign melanocytic lesions in 1765 patients undergoing short-term sequential digital dermoscopic imaging during 2.5 to 4.5 months (42.3% male; mean [SD] age, 40 [14] years; age range, 1-86 years)., Main Outcome Measures: Proportion of changed nevi as a function of age, sex, lesion diameter, and anatomical site., Results: The only variable significantly associated with nevus change was age group (P = .002). When compared with the middle-aged (aged 36-50 years) group, the odds of change were significantly increased in the child and adolescent (aged 0-18 years: odds ratio, 2.60; 95% confidence interval, 1.30-5.22), young adult (aged 19-35 years: 1.50; 1.04-2.17), and elderly (> 65 years old: 2.04; 1.04-3.99) age groups. Within the changed benign lesions, a significant association was observed between histologic subtype and age group (P = .01). The proportion of changed lesions of the banal nevi type decreased and the proportion of the dysplastic nevi type increased with age. In the elderly group, 75.9% of changed lesions were of the dysplastic nevi type compared with 35.7% in the youngest group., Conclusion: A poorer specificity is observed for the diagnosis of melanoma for nevi undergoing short-term sequential digital dermoscopic imaging in children and adolescents (75.7%) and elderly patients (77.9%) compared with other patients (84.6%).

In the past few decades, rapid improvements in noninvasive optical technologies have revolutionized the diagnosis of early-stage melanoma. Current knowledge and limitations of these tools will be reviewed in this article. Dermoscopy has been recognized as the 'gold standard' in the screening phase. Digital dermoscopy monitoring and total-body photography are used to identify so-called 'featureless' melanoma only on the criteria of change over time. Automated instruments, as well as optical and nonmorphological methods, are still under development, and offer many opportunities to improve the speed and accuracy of the diagnosis of melanoma and/or to reduce the need for expertise. Despite a penetration depth limited to the upper dermis, the quasi-histological imaging achieved by in vivo reflectance confocal microscopy has been demonstrated to significantly aid diagnostic accuracy for selected melanocytic lesions. Future perspectives on diagnostic instrumentation will also be explored.

In previous research, a watershed-based algorithm was shown to be useful for automatic lesion segmentation in dermoscopy images, and was tested on a set of 100 benign and malignant melanoma images with the average of three sets of dermatologist-drawn borders used as the ground truth, resulting in an overall error of 15.98%. In this study, to reduce the border detection errors, a neural network classifier was utilized to improve the first-pass watershed segmentation; a novel "edge object value (EOV) threshold" method was used to remove large light blobs near the lesion boundary; and a noise removal procedure was applied to reduce the peninsula-shaped false-positive areas. As a result, an overall error of 11.09% was achieved., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Nodular melanoma (NM) and amelanotic/hypomelanotic melanoma (AHM) often present a challenge to the diagnosing clinician. A significant proportion of AHM are nodular in nature. Such tumors may lack features of asymmetry and altered peripheral pigmentation routinely observed in other melanoma subtypes. This lack of distinguishing clinical features can potentially result in delayed diagnosis or inappropriate treatment. This review highlights the key points in evaluating the range of lesions where AHM or NM are considered in the differential diagnosis and summarizes current evidence in relation to pigmented and vascular dermoscopic diagnostic criteria for both., (© 2011 Japanese Dermatological Association.)

Background/purpose: Automatic lesion segmentation is an important part of computer-based image analysis of pigmented skin lesions. In this research, a watershed algorithm is developed and investigated for adequacy of skin lesion segmentation in dermoscopy images., Methods: Hair, black border and vignette removal methods are introduced as preprocessing steps. The flooding variant of the watershed segmentation algorithm was implemented with novel features adapted to this domain. An outer bounding box, determined by a difference function derived from horizontal and vertical projection functions, is added to estimate the lesion area, and the lesion area error is reduced by a linear estimation function. As a post-processing step, a second-order B-Spline smoothing method is introduced to smooth the watershed border., Results: Using the average of three sets of dermatologist-drawn borders as the ground truth, an overall error of 15.98% was obtained using the watershed technique., Conclusion: The implementation of the flooding variant of the watershed algorithm presented here allows satisfactory automatic segmentation of pigmented skin lesions.

Limited studies have reported the in vivo reflectance confocal microscopy (RCM) features of lentigo maligna (LM). A total of 64 RCM features were scored retrospectively and blinded to diagnosis in a consecutive series of RCM sampled, clinically equivocal, macules of the face (n=81 LM, n=203 benign macules (BMs)). In addition to describing RCM diagnostic features for LM (univariate), an algorithm was developed (LM score) to distinguish LM from BM. This comprised two major features each scoring +2 points (nonedged papillae and round large pagetoid cells > 20 microm), and four minor features; three scored +1 point each (three or more atypical cells at the dermoepidermal junction in five 0.5 x 0.5 mm(2) fields, follicular localization of atypical cells, and nucleated cells within the dermal papillae), and one (negative) feature scored -1 point (a broadened honeycomb pattern). A LM score of > or = 2 resulted in a sensitivity of 85% and specificity of 76% for the diagnosis of LM (odds ratio (OR) for LM 18.6; 95% confidence interval: 9.3-37.1). The algorithm was equally effective in the diagnosis of amelanotic lesions and showed good interobserver reproducibility (87%). In a test set of 29 LMs and 44 BMs, the OR for LM was 60.7 (confidence interval: 11.9-309) (93% sensitivity, 82% specificity).

Background: Early detection of basal cell carcinoma (BCC) is crucial to reduce the morbidity of this tumor., Objective: We sought to investigate the variability and diagnostic significance of dermatoscopic features of BCCs., Methods: We conducted retrospective dermatoscopic analysis of 609 BCCs and 200 melanocytic and nonmelanocytic lesions, and assessment of interrater reliability of dermatoscopic BCC criteria., Results: Lesions included nonpigmented (15.1%), lightly pigmented (33.2%), pigmented (42.7%), and heavily pigmented (9%) BCCs. Classic BCC patterns including arborizing telangiectasia (57.1%), blue/gray ovoid nests (47.5%), ulceration (39.2%), multiple blue/gray globules (26.1%), leaflike areas (15.9%), and spoke-wheel areas (9%) were significantly increased in pigmented BCCs compared with nonpigmented and heavily pigmented BCCs (P = .0001). Among nonclassic BCC patterns, we detected short fine superficial telangiectasia (10%) and multiple small erosions (8.5%), and described two new patterns named "concentric structures" (7.6%) and "multiple in-focus blue/gray dots" (5.1%). Dermatoscopic features suggestive of melanocytic lesions (eg, multiple brown to black dots/globules, blue/white veillike structures, and nonarborizing vessels) were observed in 40.6% BCCs and significantly increased in heavily pigmented BCCs (P < .0001). Expert observers provided an accurate (sensitivity: 97%) and reliable (K: 87%) dermatoscopic diagnosis of BCC, although a significant difference in terms of specificity (P = .0002) and positive predictive value (P = .0004) was found. Arborizing telangiectasia, leaflike areas, and large blue/gray ovoid nests represented reliable and robust diagnostic parameters., Limitation: The study was retrospective., Conclusion: BCCs show a large spectrum of global and local dermatoscopic features; heavily pigmented BCCs show the most challenging combinations of dermatoscopic features.

Objective: To test the interobserver and intraobserver reproducibility of the standard terminology for description and diagnosis of melanocytic lesions in in vivo confocal microscopy., Design: A dedicated Web platform was developed to train the participants and to allow independent distant evaluations of confocal images via the Internet., Setting: Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy., Participants: The study population was composed of 15 melanomas, 30 nevi, and 5 Spitz/Reed nevi. Six expert centers were invited to participate at the study. Intervention Evaluation of 36 features in 345 confocal microscopic images from melanocytic lesions., Main Outcome Measure: Interobserved and intraobserved agreement, by calculating the Cohen kappa statistics measure for each descriptor., Results: High overall levels of reproducibility were shown for most of the evaluated features. In both the training and test sets there was a parallel trend of decreasing kappa values as deeper anatomic skin levels were evaluated. All of the features, except 1, used for melanoma diagnosis, including roundish pagetoid cells, nonedged papillae, atypical cells in basal layer, cerebriform clusters, and nucleated cells infiltrating dermal papillae, showed high overall levels of reproducibility. However, less-than-ideal reproducibility was obtained for some descriptors, such as grainy appearance of the epidermis, junctional thickening, mild atypia in basal layer, plump bright cells, small bright cells, and reticulated fibers in the dermis. Conclusion The standard consensus confocal terminology useful for the evaluation of melanocytic lesions was reproducibly recognized by independent observers.

Background: Spitz nevi are benign melanocytic tumors, sometimes misdiagnosed as malignant melanoma (MM)., Objective: We sought identification of characteristic in vivo microscopic features of Spitz nevi, their histopathologic correlates, and diagnostic usefulness., Methods: Forty Spitz nevi were studied by in vivo confocal microscopy and dermatoscopy, evaluating histopathologic correlates, and compared with 40 MMs and 40 Clark nevi., Results: Some histologic aspects characteristic for Spitz nevus diagnosis were correlated with confocal features, comprising some that can be useful for atypical Spitz nevus classification. The most striking features for differentiating Spitz nevi from MMs were the presence of sharp border cut-off, junctional nests, and melanophages., Limitations: No correlates were found for other aspects, such as Kamino bodies, hyperkeratosis, acanthosis, mitoses, and maturation with depth. The impossibility of exploring deeper aspects hampered an accurate distinction from MMs in some cases., Conclusion: Confocal and dermatoscopic examination enabled the identification of different Spitz categories with different histologic substrates.

Objective: To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma., Design: A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions., Setting: Predominantly hospital-based clinics from 5 continents., Main Outcome Measures: Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy., Results: The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

Background: As a result of advances in skin imaging technology and the development of suitable image processing techniques, during the last decade, there has been a significant increase of interest in the computer-aided diagnosis of melanoma. Automated border detection is one of the most important steps in this procedure, because the accuracy of the subsequent steps crucially depends on it., Methods: In this article, we present a fast and unsupervised approach to border detection in dermoscopy images of pigmented skin lesions based on the statistical region merging algorithm., Results: The method is tested on a set of 90 dermoscopy images. The border detection error is quantified by a metric in which three sets of dermatologist-determined borders are used as the ground-truth. The proposed method is compared with four state-of-the-art automated methods (orientation-sensitive fuzzy c-means, dermatologist-like tumor extraction algorithm, meanshift clustering, and the modified JSEG method)., Conclusion: The results demonstrate that the method presented here achieves both fast and accurate border detection in dermoscopy images.