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Background: In a recent report we described RPE65, a protein originally characterized in retinal pigment epithelium, to be expressed in normal human epidermis. RPE65 is suspected to be involved in cellular uptake of retinol which is transported in the bloodstream complexed with plasma retinol-binding protein., Objectives: To evaluate protein and mRNA expression of RPE65 in actinic keratosis (AK), squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) compared with normal skin., Methods: RPE65 mRNA expression in skin tumours relative to normal skin of the respective donor was studied by real-time polymerase chain reaction in AK (n = 15), invasive SCC (n = 30) and BCC (n = 18). A peptide-specific anti-RPE65 antibody was used for immunohistochemical staining of formalin-fixed and paraffin-embedded tissue sections of the respective tumours., Results: RPE65 mRNA expression was reduced in AK. A highly significant reduction of RPE65 mRNA was observed in invasive SCC relative to normal skin of the respective donors. Immunohistochemistry revealed a continuous staining of basal and suprabasal keratinocytes in normal human epidermis. RPE65 in AK shown by immunohistochemical staining was reduced and quite irregular, whereas invasive SCC revealed no staining of tumour cells with the anti-RPE65 antibody. RPE65 mRNA values were elevated, whereas immunohistochemical staining for RPE65 protein was heterogeneous in BCC., Conclusions: These results suggest progressive downregulation of RPE65 from AK to invasive SCC.

It has been demonstrated that thalidomide's anti-angiogenic properties result in clear anti-tumor activity in a number of human malignancies. We studied thalidomide in a human melanoma severe combined immunodeficiency mouse xenotransplantation model. Thalidomide as a single agent showed a significant tumor reduction of 46% compared with the control group. Thalidomide combined with dacarbazine treatment markedly enhanced the anti-tumor effect of chemotherapy and showed a significant tumor reduction relative to the dacarbazine-only group (61%) and even more tumor reduction (74%) compared with the control group. We also measured clearly reduced levels of tumor necrosis factor-alpha in the thalidomide-treated group. A significantly lower microvessel density was encountered in the thalidomide treatment groups (thalidomide alone or combined with DTIC), underscoring the anti-angiogenic effect of thalidomide as a single agent as well as in combination with chemotherapy in this model. In line with these results, we observed a nearly 3-fold increase of apoptosis for the combination of thalidomide and DTIC compared with the rate of apoptotic cells in DTIC-only-treated melanoma xenotransplants. These data underline the rationale for combining dacarbazine--a cytotoxic agent--and thalidomide--an anti-angiogenic cytostatic agent--as a promising strategy for the treatment of melanoma.

The lack of efficacy of available therapies for the treatment of malignant melanoma has emphasized the need to develop novel therapeutic strategies to prevent melanoma growth. We have tested whether the anti-HMW-MAA mAb 225.28S is able to inhibit human melanoma tumor growth in SCID mice because in vitro data suggested that this antigen plays a role in spreading, migration and invasion of melanoma cells. Tumors were established by subcutaneous injection of the human melanoma cell line 518A2 into SCID mice. When tumors reached a size of 5 mm, the mAb 225.28S was administered intravenously 4 times in 3 day intervals at 100 microg/injection. Within 14 days after the first administration of the mAb 225.28S, tumor growth was reduced by 52% as compared to control mice. Three hundred and seven genes of >20,000 genes contained on the GeneChip were changed in their expression level at least 2-fold after administration of the mAb 225.28S. The encoded proteins were mostly components or modifiers of the extracellular matrix, tumor suppressors, and melanogenesis associated proteins. Surprisingly, the administration of the control mAb that did not lead to a significant tumor growth inhibition in vivo resulted in the modulation of two-thirds of these genes. This is the first report of suppression of human melanoma tumor growth in SCID mice by the mAb 225.28S. Our results suggest that anti-HMW-MAA mAbs may represent useful reagents to apply passive immunotherapy to patients with malignant melanoma., ((c) 2004 Wiley-Liss, Inc.)

Sentinel lymph node biopsy (SLNB) has become a widely accepted standard procedure in the staging of patients with cutaneous melanoma and absence of clinical lymph node metastases, although there is no final proof that SLNB influences overall survival in these patients. This study investigated the accuracy of SLNB and the clinical outcome of patients after a mean follow-up of 22 months. Between 1998 and 2003, SLNB was performed in 309 consecutive patients. Patients with one or more positive sentinel lymph nodes (SLNs) were subjected to selective lymphadenectomy (SL). Survival analyses were performed using the Kaplan-Meier approach. A Cox proportional-hazard analysis was used for univariate and multivariate analysis to explore the effect of variables on survival. Sentinel lymph nodes were identified in 299 of 309 patients (success rate: 96.8%). Of these, 69 (23%) had a positive SLN. The false-negative rate was 9.2%. Recurrence of disease to the regional lymph node basin (3.0%) and to the locoregional skin (2.6%) was rare in SLN-negative patients in contrast to SLN-positive patients (7.2 and 17.4%, respectively). The 3-year overall survival was 93 and 83% for SLN-negative and SLN-positive patients, respectively. Upon multivariate analysis, SLN status (P<0.001), Breslow thickness (P<0.02) and ulceration (P<0.026) were all found to be independent prognostic factors with respect to disease-free survival, whereas Breslow thickness proved to be the only significant factor with respect to overall survival.

Peptide mimotopes of tumor antigen epitopes have been proposed as components of tumor vaccines. In this study, we determined the immunogenicity of melcam mim1 and melcam mim2, peptide mimics of an epitope of the melanoma cell-adhesion molecule (Mel-CAM). BALB/c mice were vaccinated either with mimotopes or mimotopes coupled to tetanus toxoid (TT). The antibody responses of mice to melcam mim1, melcam mim2, and recombinant Mel-CAM were analyzed by an ELISA and immunoblot analyses. TT-coupled mimotopes led to high titers of IgG mainly of the IgG2a subclass to melcam mim1 and melcam mim2. Immunization with each of the mimotope formulations induced antibodies that cross-reacted with recombinant Mel-CAM. Uncoupled mimotopes induced lymphocyte proliferation and cytokine production in spleen cell cultures indicating that both peptide mimotopes also contained T cell epitopes. TT-coupled mimotopes induced T helper (Th)1 (interleukin (IL)-2, interferon-gamma) and Th2 (IL-4, IL-5) cytokines, whereas uncoupled mimotopes induced a Th1-biased T cell response. Our results suggest that mimotopes potentially represent a novel vaccine approach to induce a tumor antigen-specific humoral and cellular response.

Interferon-alpha (IFN-alpha) is widely used for the treatment of viral infections and primary cancers. In the present study, we investigated whether the anti-proliferative activity of IFN-alpha is capable of inhibiting melanoma tumor development in the absence of protective immune responses in a severe combined immunodeficiency (SCID) mouse model. Mice treated with either regular (100 microg/3 times per week) or pegylated (300 microg/once weekly) human IFN-alpha 2a showed a marked reduction in tumor weight after 4 wk of treatment. Tumor weight in pegylated and conventional IFN-alpha-treated animals was reduced by 61% and 67%, respectively, as compared to saline control (both p< or =0.01). A decrease of proliferation and an increase of apoptotic tumor cells were observed in IFN-treated tumors. DNA microarrays were applied to analyze transcriptional responses in tumors after 4 wk of treatment and a subset of about 90 genes was differentially expressed. Twenty-four novel and five known interferon-inducible genes were up- and 65 genes downregulated. A direct comparison of IFN-alpha and pegylated IFN-alpha did not reveal any significant differences in tumor growth inhibition indicating that this novel and more stable class of IFN is functionally equivalent. Despite the structural difference between pegylated and conventional IFN-alpha, both agents caused similar transcriptional responses in human melanoma xenotransplants.

Mutations in the BRAF-gene are found in benign and malignant melanocytic lesions, >90% being a V599E mutation. This mutation results in constitutively active kinase function and increased colony formation in vitro. The biological impact of this mutation in vivo is still debated. To address this question, we used our digital epiluminescence image archive and retrospectively selected 49 melanocytic lesions, which did not meet the criteria of melanoma at the initial presentation. Mean 12 months later these lesions were excised because of increased size or changed structure and BRAF(V599E) mutations were analyzed. Among 36 growing lesions, BRAF(V599E) mutations were found in 16 (11 melanomas and 5 nevi). Among 13 lesions with structural changes, BRAF(V599E) mutations were found in 4 (3 melanomas and 1 nevus). Thirty-five randomly selected additional lesions with no changes during follow-up served as controls, all nevi by histology, and two of them showed a BRAF(V599E) mutation. Statistics revealed odds for the presence of the BRAF(V599E) mutation being seven times higher in lesions with structural changes and 13 times higher in growing lesions as compared with lesions without changes. This raises the question if the V599E mutation determines lesions at risk developing into melanoma and if not, what are the mechanisms controlling growth stop in benign lesions?

For patients with advanced malignant melanoma, the 5 y survival rate with current treatment modalities is low. There is an urgent need for more effective therapeutic concepts. One approach with great potential is to stimulate the body's own immune defense to reject cancer cells using CpG oligonucleotides. Distinct oligonucleotides containing nonmethylated cytidine residues in cytidine-guanosine dinucleotides with particular flanking bases (CpG motifs) are capable of eliciting powerful immune stimulation by mimicking infectious disease. We evaluated the in vivo antitumoral effects of CpG oligonucleotides against human malignant melanoma xenografts in NOD/SCID mice. CpG oligonucleotides administered in single peritumoral subcutaneous injections three times per week resulted in elevated plasma levels of interleukin-12 and significant inhibition of the growth of established tumor xenografts by 60% (p<0.016) compared to the saline control. In addition to this a significant invasion of macrophages into tumor xenografts and increased numbers of Langerhans-cell-derived dendritic cells in draining lymph nodes could be observed. Our findings demonstrate the antitumor activity of oligonucleotides containing immune-stimulatory CpG motifs in a xenotransplantation model with absent B, T cells and a lack of natural killer cell function.

It is well established that high expression of the antiapoptotic Bcl-2 family proteins Bcl-2 and Bcl-xL can significantly contribute to chemoresistance in a number of human malignancies. Much less is known about the role the more recently described Bcl-2 family member Mcl-1 might play in tumor biology and resistance to chemotherapy. Using an antisense strategy, we here address this issue in melanoma, a paradigm of a treatment-resistant malignancy. After in vitro proof of principle supporting an antisense mechanism of action with specific reduction of Mcl-1 protein as a consequence of nuclear uptake of the Mcl-1 antisense oligonucleotides employed, antisense and universal control oligonucleotides were administered systemically in combination with dacarbazine in a human melanoma SCID mouse xenotransplantation model. Dacarbazine, available now for more than three decades, still remains the most active single agent for treatment of advanced melanoma. Mcl-1 antisense oligonucleotides specifically reduced target protein expression as well as the apoptotic threshold of melanoma xenotransplants. Combined Mcl-1 antisense oligonucleotide plus dacarbazine treatment resulted in enhanced tumor cell apoptosis and led to a significantly reduced mean tumor weight (mean 0.16 g, 95% confidence interval 0.08-0.26) compared to the tumor weight in universal control oligonucleotide plus dacarbazine treated animals (mean 0.35 g, 95% confidence interval 0.2-0.44) or saline plus dacarbazine treated animals (mean 0.39 g, 95% confidence interval 0.25-0.53). We thus show that Mcl-1 is an important factor contributing to the chemoresistance of human melanoma in vivo. Antisense therapy against the Mcl-1 gene product, possibly in combination with antisense strategies targeting other antiapoptotic Bcl-2 family members, appears to be a rational and promising approach to help overcome treatment resistance of malignant melanoma.

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. kappa 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 kappa 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.

Paclitaxel is an alkaloid that inhibits endothelial cell proliferation, motility, and tube formation at nanomolar concentrations. Cationic liposome preparations have been shown to target blood vessels. We wished to explore the possibility that paclitaxel encapsulated in cationic liposomes carries paclitaxel to blood vessels and thereby provides an antiangiogenic effect. We used a humanized SCID mouse melanoma model, which allowed us to analyze tumor growth and tumor angiogenesis in an orthotopic tumor model. Here, human melanoma cells grow on human dermis and are in part nourished by human vessels. We show that paclitaxel encapsulated in liposomes prevents melanoma growth and invasiveness and improves survival of mice. Moreover, liposome-encapsulated paclitaxel reduces vessel density at the interface between the tumor and the human dermis and reduces endothelial cell mitosis to background levels. In contrast, equimolar concentrations of paclitaxel solubilized in Cremophor EL(R) had only insignificant effects on tumor growth and did not reduce the mitotic index of endothelium in vivo, although the antiproliferative effect of solubilized paclitaxel in Cremophor EL(R)in vitro was identical to that seen with liposome-coupled paclitaxel. In conclusion, we present a model of how to exploit cytotoxic effects of compounds to prevent tumor growth by using cationic liposomes for targeting an antiproliferative drug to blood vessels.

Background: Recent developments in computer technology have raised expectations that fully automated diagnostic instruments will become available to diagnose cutaneous melanoma without the need of human expertise., Objectives: To critically review the contemporary literature on computer diagnosis of melanoma, evaluate the accuracy of such computer diagnosis, analyze the influence of study characteristics, and compare the accuracy of computer diagnosis of melanoma with human diagnosis., Methods: Quantitative meta-analysis of published reports., Data Sources: Eligible studies were identified by a MEDLINE search covering the period from January 1991 to March 2002, by manual searches of the reference lists of retrieved articles, and by direct communication with experts., Results: Thirty studies with substantial differences in methodological quality were deemed eligible for meta-analysis. Five of these complied with the predetermined list of "good quality" requirements, but none met all methodological quality requirements. Ten of these studies compared the performance of computer diagnosis with human diagnosis. The diagnostic accuracy achieved with computer diagnosis was statistically not different from that of human diagnosis (log odds ratios, 3.36 vs 3.51; P =.80). The diagnostic performance of the computer diagnosis was better for studies that used dermoscopic images than for studies that used clinical images (log odds ratios, 4.2 vs 3.4; P =.08). Other study characteristics did not significantly influence the accuracy of the computer diagnosis., Conclusions: The computer diagnosis of melanoma is accurate under experimental conditions, but the practical value of automated diagnostic instruments under real-world conditions is currently unknown. We suggest minimum requirements for methodological quality in future experimental studies or, ideally, randomized controlled trials.

Malignant melanoma is a tumor that responds poorly to a variety of apoptosis-inducing treatment modalities, such as chemotherapy. The expression of genes that regulate apoptotic cell death plays an important role in determining the sensitivity of tumor cells to chemotherapeutic intervention. Bcl-x(L) is an antiapoptotic member of the Bcl-2 family and is universally expressed in human melanoma. To evaluate the Bcl-x(L) protein as a potential therapeutic target in melanoma, the influence of Bcl-x(L) expression levels on the chemoresistance of human melanoma cells was investigated. Overexpression of Bcl-x(L) in stably transfected human melanoma Mel Juso cells significantly reduced sensitivity to cisplatin-induced apoptosis (p < or = 0.05). In a parallel approach, reduction of Bcl-x(L) protein by specific AS oligonucleotide (ISIS 16009) treatment enhanced the chemosensitivity of Mel Juso cells by 62% compared to cells treated with MM control oligonucleotide (ISIS 16967) as well as chemotherapy-induced apoptosis. These data suggest that Bcl-x(L) is an important factor contributing to the chemoresistance of human melanoma. Reduction of Bcl-x(L) expression by AS oligonucleotides provides a rational and promising approach that may help to overcome chemoresistance in this malignancy., (Copyright 2002 Wiley-Liss, Inc.)

The accuracy of the dinical diagnosis of cutaneous melanoma with the unaided eye is only about 60%. Dermoscopy, a non-invasive, in vivo technique for the microscopic examination of pigmented skin lesions, has the potential to improve the diagnostic accuracy. Our objectives were to review previous publications, to compare the accuracy of melanoma diagnosis with and without dermoscopy, and to assess the influence of study characteristics on the diagnostic accuracy. We searched for publications between 1987 and 2000 and identified 27 studies eligible for meta-analysis. The diagnostic accuracy for melanoma was significantly higher with dermoscopy than without this technique (log odds ratio 4.0 [95% CI 3.0 to 5.1] versus 2.7 [1.9 to 3.4]; an improvement of 49%, p = 0.001). The diagnostic accuracy of dermoscopy significantly depended on the degree of experience of the examiners. Dermoscopy by untrained or less experienced examiners was no better than clinical inspection without dermoscopy. The diagnostic performance of dermoscopy improved when the diagnosis was made by a group of examiners in consensus and diminished as the prevalence of melanoma increased. A comparison of various diagnostic algorithms for dermoscopy showed no significant differences in their diagnostic performance. A thorough appraisal of the study characteristics showed that most of the studies were potentially influenced by verification bias. In conclusion, dermoscopy improves the diagnostic accuracy for melanoma in comparison with inspection by the unaided eye, but only for experienced examiners.

The new morphological information provided by epiluminescence microscopy (ELM) requires a fresh approach to the analysis of pigmented lesions. It necessitates a learning process that pertains to the recognition of hitherto unknown morphological features and is based on the discrimination of these features and their combination into two different patterns. ELM has been shown to improve the sensitivity and specificity of the diagnosis of melanoma and other pigmented lesions by 25-30%. Digitized ELM (DELM) provides an unlimited capacity for data storage and retrieval. It is a computerized imaging method, objective and noninvasive; it provides objective evidence of lesional changes on follow-up; documents growth and any changes in the structure and shape of lesions; and thus helps in decisions on whether to excise them or not. It provides for quality control by means of the aforementioned documentation, which may also serve as back-up in the case of medico-legal problems. In addition, the spectrum is widened by the dimension of teledermatology and cybernet computer-assisted diagnosis, which holds great promise for the future. ELM and DELM are thus the most important single development of the past three decades in the early diagnosis of melanoma.

The aim of this study was to report on the compliance with follow-up among patients with thin melanomas. We also examined the prognosis of patients with recurrent disease and whether there were any differences in prognosis associated with the time between the last follow-up examination and the onset of recurrence. A retrospective analysis of the records of 513 consecutive patients (50.3% males, mean age: 52.8+/-16.9 years) with thin melanomas (<1.5 mm Breslow thickness) was carried out. The estimated cumulative proportion of patients who still continued their follow-up examinations 5 years after diagnosis of the primary tumour was 55.3% (95% Confidence Interval (CI): 50.4--60.2%). The mean annual drop-out rate was 11.2%. The drop-out rate was similar for males and females and was not influenced by the patients' age or the tumour thickness. Among 263 patients who continued follow-up, 50.2% (n=132) were not compliant with the time schedule. 20 patients presented with recurrent disease after a median of 35.9 months (25--75% percentiles: 16.7--46.5 months). Six patients who did not have a follow-up examination within 1 year before the onset of recurrence presented with more advanced disease and had a worse prognosis (median survival: 12.5 months, hazard ratio: 3.5, 95% CI: 1.1--17.1, P=0.04), than those patients, who had a recent follow-up examination before the onset of recurrence (n=14, median survival: 22.3+ months). In the majority of recurrent cases with good prognosis, metastatic disease was confined to the regional lymph nodes and the presumptive diagnosis of metastatic disease was either made by palpation or by sonography of the regional lymph nodes. The observed drop-out rate of patients during the first 5 years of follow-up is substantial and does not depend on the patients' age, sex or on the tumour thickness. Although the frequency of recurrences among patients with thin melanomas is low, regular follow-up examinations including physical examination, as well as palpation and sonography of the regional lymph nodes, are essential.

Based on evidence that granulocyte-macrophage colony stimulating factor (GM-CSF) induces a potent systemic antitumor immunity, we tested recombinant GM-CSF in advanced melanoma. Seven patients with histologically confirmed cutaneous melanoma metastases were treated with perilesional intracutaneous injections of recombinant GM-CSF and observed for a follow-up time of 5 y. All but two patients had a decrease in the total number of metastases. At the end of the 5 y follow-up three of the seven patients are still alive with only one patient receiving other than surgical therapy, and one patient died tumor free at the age of 93. The remaining three patients died from progressive melanoma. Perilesional intradermal GM-CSF therapy resulted in a mean survival time of 33 mo. The treatment was well tolerated and no side-effects other than local erythema at the injection sites and mild drowsiness were seen. Immunohistochemical analysis with staining for CD14 and GM-CSF receptor demonstrated an increased infiltration of monocytes into both injected and noninjected cutaneous melanoma metastases compared with lesions excised prior to the initiation of therapy. The same was true for CD4- and CD8-positive lymphocytes. This phenomenon, together with GM-CSF-induced leukocyte counts of more than 20,000 during therapy, support the possible impact of a systemic over a locally induced reaction by GM-CSF. To our knowledge this is the first report that intracutaneously injected GM-CSF results in long-lasting reduction of melanoma metastases.

Background: The aim of the study is to provide recent demographic data on cutaneous melanoma in Austria., Patients and Methods: Patients with primary cutaneous melanoma diagnosed between January 1, 1990 and December 31, 1999 were included in the analysis. Data were retrieved from the melanoma registry of the University Department of Dermatology in Vienna., Results: In the observation period, 2501 cutaneous melanomas were diagnosed in 2427 patients (mean age: 55.4 yrs; 51.2% females). A total of 267 (10.7%) cutaneous melanomas were in situ, and 2234 (89.3%) were invasive. The median invasion thickness according to Breslow for invasive melanomas was 0.98 mm (25%-75% percentiles: 0.55-2.00 mm). We observed a significant trend towards thicker tumors with increasing age (p < 0.001). In patients less than fifty years of age, a significantly higher Breslow thickness was observed in men than in women (0.90 mm versus 0.80 mm, p = 0.03). The median Breslow thickness of invasive melanoma decreased from 1.20 mm in 1990 to 0.92 mm in 1999 (p for trend, < 0.001). Compared to women, men had melanomas more frequently on the back (43.8% versus 24.4%, p < 0.001). In women, melanomas were more frequently found on the lower legs than in males (21.5% versus 6.7%, p < 0.001). In a multivariate model, invasion thickness according to Breslow was the single most important predictor of survival., Conclusion: Our data confirm recent reports from other European countries with regard to the decline in tumor thickness of cutaneous melanoma. Our data also demonstrate a need for improving early diagnosis, particularly in certain subgroups of patients.

Early melanoma is often difficult to differentiate from benign pigmented skin lesions (PSLs). Digital epiluminescence microscopy (DELM) and automated image analysis could represent possible aids for inexperienced clinicians. We designed an automated computerized image analysis system that has the potential for use as an additional tool for the differentiation of melanoma from dysplastic naevi and common naevi. The PC-based pilot system was attached to a common DELM system as the image source. Digital images of PSLs were automatically segmented and a panel of 107 morphological parameters were measured. Additionally, seven clinical parameters were evaluated and used as an additional source of information. Neural networks were then trained to distinguish melanoma from benign PSLs. One class of networks was trained solely based on the morphometric features, whereas the second class of networks was trained on the combination of morphometric and clinical features. The automatic segmentation algorithm was correct in 96% of cases. Using three-way receiver operating characteristic (ROC) analysis, for networks trained solely on morphometric features the volume under surface (VUS) was 0.617 (SD 0.036). The performance was significantly better for networks trained on the combination of both morphometric and clinical features (VUS = 0.682, SD 0.035). In a dichotomous model, distinguishing benign lesion (common naevi + dysplastic naevi) from melanoma, the area under the curve (AUC) from two-way ROC analysis was 0.942 (SD 0.018) for networks trained solely on morphometric features and 0.968 (SD 0.012) for those trained on the combination of clinical and morphometric data (P= NS). Automated feature extraction from PSLs and the training of neural networks as classifiers has thus shown satisfactory performance in a large scale experiment. The addition of clinical data significantly increases the diagnostic performance for distinguishing three classes of lesions (i.e. common naevi, dysplastic naevi and melanoma). Such integrated systems hold promise as a decision aid for the diagnosis of PSLs.

Background: Digital epiluminescence microscopy (DELM) has been reported to be a useful technique for the follow-up of melanocytic nevi. One of the promises of this technique is to identify modifications over time that indicate impending or incipient malignancy and to facilitate surveillance of melanocytic skin lesions, particularly in patients with multiple clinically atypical nevi., Objective: Our purpose was to report on patterns of modifications over time observed in benign melanocytic skin lesions and melanoma., Methods: A total of 1862 sequentially recorded DELM images of melanocytic lesions from 202 patients (mean age, 36.1 years; 54.0% female patients) with multiple clinically atypical nevi were included in the analysis. The median follow-up interval was 12. 6 months. Melanocytic lesions with substantial modifications over time (enlargement, changes in shape, regression, color changes or appearance of ELM structures known to be associated with melanoma) were excised and referred to histopathologic examination., Results: A total of 75 melanocytic skin lesions (4.0%) from 52 patients (mean age, 33.3 years; 63.5% female patients) showed substantial modifications over time and were excised and referred to histopathologic examination. Eight changing lesions were histologically diagnosed as early melanomas. These lesions frequently showed focal enlargement associated with a change in shape as well as appearance of ELM structures that are known to be associated with melanoma. In contrast, the majority of benign changing lesions (common and atypical nevi) showed symmetric enlargement without substantial structural ELM changes. Six of the 8 patients in whom melanoma developed were unaware of the fact that the lesion had changed over time., Conclusion: We demonstrate that follow-up of melanocytic lesions with DELM helps to identify patterns of morphologic modifications typical for early melanoma. DELM may therefore serve as a useful tool to improve the surveillance of patients with multiple atypical nevi.

Merkel cell carcinoma (MCC) is a neuroendocrine malignancy showing poor response to a variety of therapeutic strategies. We evaluated the antitumor activity of S-trans, trans-farnesylthiosalicylic acid (FTS), a new inhibitor of Ras signal transduction, in a newly established SCID mouse xenotransplantation model for human MCC (seven animals per group). FTS injected intraperitoneally at 5 mg/kg per day for 2 weeks up-regulated the tumor suppressor p53 and induced tumor cell apoptosis in established MCCs growing subcutaneously in SCID mice. These effects led to a statistically significant inhibition of MCC growth (P<0.002). The mean tumor weights following FTS or control treatment were 0.32+/-0.15 g and 1.08+/-0.29 g, respectively. There was no evidence of FTS related toxicity at the effective dose used. Our findings stress the notion that FTS may qualify as a novel and rational treatment approach for MCC and possibly for other tumors that rely on tyrosine kinase signaling.

We performed a phase I trial to evaluate the safety and tolerability of repeated skin injections of IL-2-transfected autologous melanoma cells into patients with advanced disease. Cell suspensions, propagated from excised metastases, were IL-2 gene transfected by adenovirus-enhanced transferrinfection and X-irradiated prior to injection. Vaccine production was successful in 54% of the patients. Fifteen patients (37%) received two to eight skin vaccinations of either 3 x 10(6) (intradermal) or 1 x 10(7) (half intradermal, half subcutaneous) transfected melanoma cells per vaccination (secreting 140-17,060 biological response modifier program units of IL-2/10(6) cells/24 hr). Analyses of safety and efficacy were carried out in 15 and 14 patients, respectively. Overall, the vaccine was well tolerated. All patients displayed modest local reactions (erythema, induration, and pruritus) and some experienced flu-like symptoms. Apart from newly appearing (4 of 14) and increasing (5 of 14) anti-adenovirus and newly detectable anti-nuclear antibody titers (1 of 15), recipients developed de novo or exhibited increased melanoma cell-specific delayed-type hypersensitivity (DTH) reactions (8 of 15) and vitiligo (3 of 15) and showed signs of tumor regression (3 of 15). This supports the idea of a vaccine-induced or -amplified anti-cancer immune response. None of the patients exhibited complete or partial regressions, but five of them experienced periods of disease stabilization. Three of these individuals received more than the four planned vaccinations and their mean survival time was 15.7 +/- 3.5 months as compared to 7.8 +/- 4.6 months for the entire patient cohort. These data indicate that IL-2-producing, autologous cancer cells can be safely administered to stage IV melanoma patients and could conceivably be of benefit to patients with less advanced disease.

Background: Epiluminescence microscopy (ELM) significantly increases the early diagnosis of pigmented skin lesions (PSL) using established criteria and pattern analysis. The ABCD rule for dermatoscopy (ie, ELM) provides a simplified approach to the interpretation of ELM images on the basis of asymmetry (A), border (B), color (C), and dermatoscopic structure (D)., Objective: We set out to determine whether the diagnostic accuracy of the ABCD scoring algorithm can be significantly improved by incorporating information about morphologic changes of the lesion observed and provided by the patient., Methods: We prospectively collected 356 small pigmented skin lesions (< 1 cm) including 73 (20.5%) melanomas. Before excision all patients were asked whether the lesion had changed in size, color, or shape within the last year or whether they experienced any sign of ulceration or spontaneous bleeding. ELM images of the lesions were evaluated according to the ABCD rule for dermatoscopy to yield a semiquantitative score. Accuracy of diagnosis was evaluated in terms of sensitivity, specificity, and area under receiver operating characteristic curves (AUC)., Results: The frequency of reported changes was significantly higher for melanomas than benign PSL (65.8% vs 29.7%, P < .001). In a multivariate model morphologic change was a significant independent predictor of malignancy (odds ratio = 3.17, 95% confidence interval [CI]: 1.96 to 5.14, P < .001). The mean final score achieved when using the enhanced ABCD-E criteria including morphologic change (E) was significantly higher for melanomas (5.7, 95% CI: 5.3 to 6.0) than benign PSL (2.9, 95% CI: 2.8 to 3.1, P < .001). Diagnostic accuracy was significantly higher when the lesions were evaluated by the enhanced ABCD-E criteria as compared with the standard ABCD score (AUC(ABCD) = 0.87 vs AUC(ABCD-E) = 0.90; P = .006)., Conclusion: Information about morphologic changes of PSL as reported by the patient is a useful extension of the ABCD rule for dermatoscopy.

Background: Epiluminescence microscopy (ELM) provides for increased accuracy in the clinical diagnosis of pigmented skin lesions (PSL). It is based on pattern analysis of ELM criteria, which requires experience. The recently introduced application of the ABCD score to ELM facilitates this by permitting lesion evaluation on the basis of predefined clinical criteria., Objective: The present study was performed to evaluate the diagnostic performance of the ABCD rule for ELM in pigmented skin lesions testing dermatologists with varying skills from novice to expert., Methods: Two hundred fifty electronic images of randomly selected, histologically proven PSL including 41 early melanomas (16.4%) were presented to the raters, and each image was scored according to the rules of the ABCD score and rated without the guidance of a scoring system on a scale from 1 = definitely benign to 5 = definitely melanoma., Results: Our data show that the application of the ABCD rule significantly enhances diagnostic ability in less experienced dermatologists compared with rating without the guidance of a scoring system. In contrast, the diagnostic accuracy of dermatologists who are moderately to greatly experienced is not improved by use of the ABCD rule., Conclusion: Our experiments indicate that the application of the ABCD rule to ELM introduced by Stolz et al represents a useful enhancement for diagnosis of pigmented skin lesions in less experienced users. However, the method does fail to detect melanomas with 100% accuracy. Therefore further effort has to be made to make the diagnosis of melanoma easier and more accurate.

Despite the poor prognosis of metastatic malignant melanoma, polychemotherapy with dacarbazine and fotemustine has shown promising results in several studies. We report on the clinical efficacy of a new sequential administration regimen with dacarbazine at a dose of 200 mg/m2 followed 24 h later by fotemustine 100 mg/m2 every 4 weeks in 63 patients with metastatic melanoma. A complete response was noted in 3 patients (5%), a partial response in 4 patients (6%), stable disease in 33 patients (5%) and progressive disease in 23 patients (37%). The duration of the 3 complete responses was 5, 14+ and 60+ months, for the 4 partial responses, 3, 4, 6 and 13 months. The median duration for stable disease was 4 months. The best response rates were obtained for lung and lymph node metastases. Toxicity was mild and mainly limited to haematological without pulmonary side-effects. Although there was a relatively low objective response rate, this chemotherapy regimen as a palliative treatment, is potentially valuable for patients with progressive stage IV melanoma.

Keratoacanthoma (KA) is a fairly common neoplasm that in the past has been considered by many to be benign. Keratoacanthoma is usually differentiated from squamous cell carcinoma (SCC) by histopathologic criteria. However, the cytologic features of KA and SCC are often similar. Hence, KA may be confused with SCC at the histopathologic level. Volume-weighted mean nuclear volume (Vv) is determined by a technique that permits an unbiased and efficient estimation of nuclear volumes in tissues without any assumptions regarding nuclear shape. In this study, the volume-weighted mean nuclear volume was determined in 18 KAs and 19 SCCs to investigate whether this stereologic approach may be of use in the differentiation of these two tumors. Vv was determined by computer-assisted image analysis (IBAS 20, Kontron, Germany) on Feulgen-stained sections employing stereologic estimation of the volume-weighted mean nuclear volume. The mean Vv of KA was 704.5 microm3 (SD +/-170.5), whereas SCC exhibited a significantly lower Vv of 533.9 microm3 (SD+/-164.9) (p = 0.006). The sensitivity and specificity of Vv for the discrimination between KA and SCC was 0.80 and 0.78, respectively. We found that KAs show a significantly larger Vv than SCCs and thus, the estimation of the volume-weighted mean nuclear volume may be regarded as a helpful tool for the differential diagnosis of KA and SCC.

Epiluminescence microscopy (ELM) is a useful method for improved diagnostic accuracy in early cutaneous melanoma. Conventional photographs of ELM images are commonly used for clinical research and documentation. Electronic images have advantages compared with photographs and are essential for medical informatics, computerized learning and telemedicine. Compression of electronic images allows a reduction in volume of data, but significant image deterioration may occur at high compression rates. We sought to study the diagnostic informativeness of compressed digital ELM images compared with conventional photographs. Fifty photographs of pigmented skin lesions, including 23 melanomas, were presented to eight dermatologists as photographic slides and as digital images with 30:1 Joint Photographic Experts Group (JPEG) compression. The diagnostic performance of the media and the readers was described in terms of sensitivity, specificity and areas under receiver operating characteristic curves (AUC). Agreement between the readings of the two types of media regarding the presence or absence of ELM criteria was assessed using kappa (kappa) statistics. The mean AUC was 0.81 (95% confidence interval [CI] = 0.73-0.90) for slides and 0.81 (95% CI = 0.72-0.90; P = 0.89) for digital images. Agreement between the readings of the two types of media regarding the presence or absence of ELM criteria ranged from kappa = 0.55 (95% CI = 0.22-0.88) for grey-blue area to kappa = 0.89 (95% CI = 0.74-1.00) for radial streaming. In conclusion, digital ELM images with 30:1 JPEG compression appear to be as informative as photographic slides when used to differentiate between melanoma and non-melanoma.

Epiluminescence microscopy (ELM) is a non-invasive technique for in vivo examination which can provide additional criteria for the clinical diagnosis of pigmented skin lesions (PSLs). In the present study we attempt to determine whether PSLs can be automatically diagnosed by an integrated computerized system. This system should recognize the PSL, automatically extract features and use these features in training an artificial neural network, which should--if sufficiently trained--be capable of recognizing and classifying a new PSL without human aid. One hundred and twenty images of randomly selected histologically proven PSLs (33 common naevi, 48 dysplastic naevi and 39 malignant melanomas) were used in this study. The images were digitally obtained and the morphological features of the PSLs were extracted electronically without human assistance. The numerical data were then divided into learning and testing cases and linked to an artificial neural network for training and for further classification of lesions that the system had not been trained on. Our results show that the computerized system was able to automatically identify 95% of the PSLs presented. The sensitivity and specificity of the computerized system were 90% and 74% respectively. In contrast, when differentiating between individual types of lesions, the system performed at true positive rates of only 38% for malignant melanoma, 62% for dysplastic naevi and 33% for common naevi. Our data indicate that (1) ELM images of PSLs provide an excellent source for digital image analysis; (2) the vast majority of PSLs can be correctly identified by a relatively simple (and thus not "intelligent") application of digital image analysis; (3) automatic feature extraction based mainly on ABCD rules provides reliable data on the distinction between benign and malignant PSLs; and (4) there is evidence that artificial neural networks can be trained to adequately discriminate between benign and malignant PSLs.

Purpose: Patients with primary cutaneous melanoma with a Breslow thickness > or = 1.5 mm have only a 30% to 70% probability of survival after surgery, and no adjuvant therapy has so far improved this outcome. Since interferon alfa-2a (IFNalpha2a) exhibits antitumor activity in metastatic melanoma, we investigated whether adjuvant IFNalpha2a diminishes the occurrence of metastases and thus prolongs disease-free survival in melanoma patients after excision of the primary tumor., Patients and Methods: In a prospective randomized study, 311 melanoma patients with a Breslow thickness > or = 1.5 mm were assigned to either adjuvant IFNalpha2a treatment (n = 154) or observation (n = 157) after excision of the primary tumor. IFNalpha2a was given daily at a dose of 3 mIU subcutaneously (s.c.) for 3 weeks (induction phase), after which a dose of 3 mIU s.c. three times per week was given over 1 year (maintenance phase)., Results: Prolonged disease-free survival was observed in patients treated with IFNalpha2a versus those who underwent surgery alone. This difference was significant (P = .02) for all patients enrolled onto the study (intention-to-treat analysis) at a mean observation time of 41 months. Subgroup analysis showed that Breslow tumor thickness had no influence on treatment results in the groups of patients investigated., Conclusion: Adjuvant IFNalpha2a treatment diminishes the occurrence of metastases and thus prolongs disease-free survival in resected primary stage II cutaneous melanoma patients.

We performed a comparative investigation of the immunomorphological characteristics of lymphatic and blood microvascular endothelial cells in normal human skin, cutaneous lymphangiomas, and hemangiomas, employing a pre-embedding immunogold electron microscopic technique. We stained for cell membrane proteins that are commonly used for light microscopic characterization of blood endothelial cells. With blood microvascular endothelial cells, we observed uniform labeling of the luminal cell membranes with monoclonal antibodies (MAbs) JC70 (CD31), EN-4 (CD31), BMA120, PAL-E, and QBEND-10 (CD34), and strong staining of the vascular basal lamina for Type IV collagen under normal and pathological conditions. In contrast, lymphatic microvascular endothelial cells in normal human skin and in lymphangiomas displayed, in addition to a luminal labeling, pronounced expression of CD31 and CD34 along the abluminal cell membranes. Moreover, CD31 was preferentially detected within intercellular junctions. The expression of CD34 was mostly confined to abluminal endothelial microprocesses and was upregulated in lymphangiomas and hemangiomas. Type IV collagen partially formed the luminal lining of initial lymphatics and occasionally formed bridges over interendothelial gaps. Our findings suggest a function of transmigration protein CD31 in recruitment of dendritic cells into the lymphatic vasculature. CD34 labeling may indicate early endothelial cell sprouting. The distribution of Type IV collagen also supports its role as a signal for migration and tube formation for lymphatic endothelial cells.

Juvenile hyaline fibromatosis (JHF) is inherited as a fatal autosomal recessive disorder characterised by multiple tumorous mucocutaneous proliferations. In this paper a 14 month old girl with JHF is described. For this condition, a malfunction of collagen synthesis is considered as the pathogenetic cause. Recently published data have revealed an absent band for type III collagen (TIIIC) chain in western blot studies of clinically unaffected JHF skin. Therefore supernatants of skin fibroblast cell cultures, obtained from normal human skin, were analysed for type 1 collagen (TIC) and TIIIC metabolites by radioimmunoassays. Besides the typical morphological connective tissue changes in the skin lesions, TIC synthesis and degradation were found increased in JHF fibroblasts compared with control fibroblasts. In contrast, TIIIC overall metabolism was significantly reduced by 36% compared with controls.

The aim of this study was to examine the efficacy of lymph node palpation versus high resolution lymph node sonography for the detection of lymph node metastases in patients with malignant melanoma. We retrospectively evaluated 2256 pairwise lymph node examinations of the cervical, axillary and inguinal region by palpation and sonography in 264 patients with resected melanomas greater than 0.75 mm of invasion thickness. Lymph node metastases occurred in 50 patients (19%) which were detected in 38 (76%) by both methods in agreement. In 7 cases (14%) palpation failed, in 3 cases (6%) sonography failed and in 2 cases both methods failed to identify metastases. The overall sensitivity of detecting metastatic disease was 82% for palpation and 90% for sonography which was statistically not different. The overall specificity by sonography (99%) was significantly better than for lymph node palpation (88%). Taking into account the results of this analysis, we conclude that patients with a negative result by lymph node palpation do not need further sonography for verification. However, any suspect result by palpation should be additionally evaluated by lymph node sonography in order to rule in or out metastatic disease.

Pigmented basal cell carcinoma (PBCC) is a tumour with distinct clinical features which occasionally may be difficult to differentiate from malignant melanoma (MM). The purpose of this study was to re-examine the epiluminescence microscopy (ELM) criteria for PBCC and to determine their statistical significance in the differential diagnosis of MM. Fifty histologically verified pigmented skin lesions (25 PBCCs and 25 MMs) were investigated using ELM for the presence of ELM criteria; their significance was determined by calculating the odds ratios. We found that individual ELM criteria have different weights of significance in the differential diagnosis of PBCC (leaf-like distribution of diffuse pigmentation, gradual thinning at the periphery and telangiectasia) and MM (pigment network, black and grey pigmentation, radial streaming, pseudopods, brown globules and black dots). Selected patterns of ELM criteria adjusted to the distinct types of pigmented skin lesions are characteristic features for preoperative diagnosis. The prevalence of distinct ELM criteria in PBCC and MM is of critical value in differentiating between the two types of lesions.

Background: Merkel cell carcinoma (MCC) is an uncommon primary neuroendocrine skin tumor most often seen in the elderly. The clinical course varies. Treatment is controversial and few data on drug sensitivity are available., Objective: We evaluated the clinical course and treatment of 10 MCC patients and determined MCC chemosensitivity., Methods: Clinical records as well as laboratory and histopathologic data from 10 patients with MCC treated in our department were examined. Chemosensitivity to various chemotherapeutic agents and interferons of MCC cells from four patients was determined in a soft agar clonogenic assay., Results: MCC behaved as an aggressive tumor with early and frequent local relapses (4 of 10 patients at a 2.2-month average), regional (4 of 10 patients at 2.5 months), and distant metastases (5 of 10 patients 9.6 months after excision of the primary tumor). In all but one patient, regional metastases preceded distant ones. Metastatic spread was associated with an average survival of 21 months from the initial diagnosis. Long-term survival (53+ and 65+ months) was observed in two women. Wide excision of the primary tumor, alone or combined with adjuvant chemotherapy and radiotherapy, was the most effective treatment. In advanced disease, chemotherapy and radiotherapy were not able to induce long-term remission. In vitro assays for MCC drug sensitivity revealed cisplatin, doxorubicin, and vindesine to be the most active., Conclusion: MCC has a poor prognosis in advanced stages; therefore the primary tumor should be aggressively treated. The in vitro clonogenic assay may help to identify the chemosensitivity profile of MCC and to optimize chemotherapy protocols.

Spitz's nevi are acquired benign melanocytic skin tumors. Usually they are differentiated from nodular melanoma by clinical and histopathological criteria. Since Spitz's nevi are one of the most common simulators of nodular melanomas their bizarre histopathology may cause diagnostic confusion and make it difficult to differentiate these two melanocytic tumors. One of the histologic features shared by Spitz's nevus and nodular melanoma is prominent vascularity. The ability of malignant melanoma to induce angiogenesis is well established whereas benign melanocytic tumors do not have a prominent overall vascularity. The purpose of this study was to find out whether the degree of vascularity of nodular melanomas differs significantly from that of benign Spitz's nevi. In this study the number of microvessels and the vessel area were determined in 23 Spitz's nevi and 16 nodular melanomas. The number of microvessels and the vessel area were determined on Ulex Europaeus agglutinin I-stained sections by computer-assisted image analysis. Two methods of measurement were used, namely systematic and selective sampling. Measurement of the whole tumor specimen (systematic sampling) revealed a vessel count of 10.83/field (SD +/-5.97) for Spitz's nevi whereas nodular melanomas exhibited a significantly lower (p=0.04) vessel count of 6.44/field (SD +/-3.85). This difference was even more pronounced when the vessel area (Spitz's nevi: 17.85x10-4mm2, SD +/-10.32; nodular melanomas: 7.88x10-4mm2, SD +/-5.23) was investigated (p < 0.001). The difference in vessel area and vessel count was insignificant for areas exhibiting the greatest vascularity (selective sampling). Measurement of vessel count and vessel area lead us to conclude that Spitz's nevi have a significantly higher vascularity than do nodular melanomas. Our results thus indicate that angiogenesis in these pigmented lesions is not correlated with malignancy.

Background: Epiluminescence microscopy (ELM) makes subsurface structures of the skin accessible for in vivo examination and provides additional criteria for the clinical diagnosis of pigmented skin lesions (PSLs). We demonstrated that ELM increases diagnostic sensitivity in dermatologists formally trained in the use of this technique but decreases diagnostic ability in dermatologists not formally trained in its application., Objective: Our purpose was to determine the effects of short formal ELM training on the diagnostic performance of 11 previously untrained dermatologists., Methods: One hundred image-pairs of randomly selected histologically proven PSLs, photographed with (ELM) and without oil immersion (surface microscopy), were presented by slide projection to the testees. To evaluate the effects on diagnostic performance before and after short-term training, we used the receiver-operator characteristics technique., Results: Without training the use of ELM did not enhance diagnostic accuracy, but rather decreased it in 8 of 11 testees. In contrast, after 9 hours of formal training in ELM the diagnostic performance of the testees was significantly enhanced with an average gain of 8.4%., Conclusion: Our data confirm that formal training is required for the useful application of the ELM technique.

Preoperative assessment of melanoma invasion by sonometry has been reported to exhibit a high correlation with postoperative histometry based on the determination of a regression coefficient. We believe that this approach is not adequate and that it can be misleading. We therefore applied an appropriate statistical approach to our data to re-examine this issue. Preoperative measurements by sonometry were compared with postoperative histometry in 71 consecutive patients with the clinical diagnosis of malignant melanoma. Patients with the histological diagnosis of melanoma in situ (n = 13) were excluded from this comparison, as sonometry cannot distinguish structures restricted to the epidermis and Breslow thickness is not routinely determined in Clark level I melanomas. The agreement between sonometry and histometry was analysed by plotting the mean of the two methods against their difference. By linear regression analysis the correlation coefficient (r) in the invasive melanomas (n = 58) was found to be 0.92. The median thickness of the invasive tumours by sonometry was 1.36 mm, and by histometry 0.89 mm. In 95% of the cases sonometry differed by 37% above to 48% below the values obtained by histometry. Thus, we conclude that the accuracy of sonometry in predicting preoperative tumour thickness- and tumour invasiveness-is far lower than previously reported.

Tumor invasion is the most reliable prognostic factor for primary stage I melanoma. "Thick" melanomas, with a Breslow thickness of more than 4 mm, tend to have a poor prognosis. Exceptions occur: some patients have no further recurrence of tumor. In an attempt to determine prognostic markers for "thick" clinical stage I melanomas, we investigated the volume-weighted mean nuclear volume of primary melanomas with tumor invasions > or = 4.0 mm in 32 patients. Seventeen of these patients developed melanoma metastases within a follow-up period of 60 mo; 15 patients who did not developed metastases and were comparable with regard to clinical and histological criteria were selected as a comparison group. Volume-weighted mean nuclear volume (Vv) is determined by a technique that permits an unbiased, efficient, shape- and orientation-independent, 3-dimensional estimation of nuclear size in tissues. This technique has been employed successfully in the prognostic assessment of stage I and II melanomas and was recently proven to be a sensitive marker for thin, high-risk melanomas. In our patients, Vv was determined by computer-assisted image analysis on Feulgen-stained sections by stereologic estimation of the Vv. The mean Vv (+/-SD) of primary melanomas with subsequent metastatic course was 794.99 +/- 209.18 micron3 (range: 409.48-1161.9 micron3), whereas primary melanoma lesions without subsequent metastases exhibited a mean Vv 640.54 +/- 205.07 micron3 (range: 206.7-927.48 micron3). This difference was found to be statistically significant (p = 0.0439). "Thick" melanomas with subsequent metastases thus exhibited a significantly higher Vv than did melanomas that did not metastasize.

Background and Design: Epiluminescence microscopy (ELM) is a noninvasive technique that, by employing the optical phenomenon of oil immersion, makes subsurface structures of the skin accessible for in vivo examination and thus provides additional criteria for the clinical diagnosis of pigmented skin lesions. At present, almost all studies about the value and clinical importance of ELM are based on data derived from ELM experts (ie, dermatologists specifically trained in this technique). In the present study, we attempt to determine whether the clinical diagnosis of pigmented skin lesions is significantly improved using ELM and whether ELM-trained individuals and dermatologists not trained in this technique profit equally from this technique. Randomly selected histologically proven pigmented skin lesion specimens, photographed with (ELM) and without oil immersion (surface microscopy) were presented by slide projection to six ELM experts and 13 ELM nonexperts (ie, dermatologists not formally trained in ELM) for diagnosis. To evaluate the diagnostic performance of ELM experts and nonexperts with and without the oil immersion technique (ie, ELM vs surface microscopy), the following parameters were obtained: intraobserver and interobserver agreement by kappa statistics and sensitivity and specificity of diagnostic performance., Results: Our results show that by using the ELM technique the ELM experts reach a substantially better intraobserver agreement than nonexperts (median kappa, 0.56 vs 0.36). The interobserver agreement was markedly increased in the ELM experts group (average gain, 7%) but decreased in the ELM nonexperts group (average loss, 6%). The sensitivity of diagnosis was significantly increased in the ELM experts group (average gain, 10%), but decreased in the nonexperts group (average loss, 10%). Finally, the specificity of diagnosis was excellent in the ELM experts group, both with and without oil immersion (0.91) and was somewhat improved by ELM in the nonexperts group (0.77 vs 0.85)., Conclusions: We conclude that the ELM technique increases sensitivity in formally trained dermatologists, but may decrease the diagnostic ability in dermatologists not formally trained in the ELM technique. Consequently, formal broad-based training in ELM should be offered to the dermatologic community.

In vivo epiluminescence microscopy (ELM) is a non-invasive technique which improves the clinical diagnosis of naevi and malignant melanoma by providing diagnostic criteria that cannot be appreciated by the naked eye. The present study investigated whether ELM criteria pattern analysis can be employed in an objective, observer-trained, computer-aided diagnostic system, and whether artificial neural networks (ANN) can be applied to the diagnosis of pigmented skin lesions (PSL). The ELM criteria patterns of 200 PSL oil immersion images (60 common naevi, 60 dysplastic naevi, and 80 malignant melanomas) were analysed using a standardized questionnaire. One hundred randomly assigned PSL were used as a training set for an ANN, the remaining 100 PSL serving as the test set. The ANN was trained by backward propagation according to the histological diagnosis, and its performance was compared with that of human investigators. Out of the test set the human investigators correctly diagnosed 88% of PSL and the ANN 86%. In a dichotomized model comparing common, compound, and dysplastic naevi vs. malignant melanoma, i.e. benign vs. malignant PSL, the sensitivity and specificity of human diagnosis was 95 and 90%, respectively, whereas the sensitivity and specificity of the ANN diagnosis was 95 and 88%. Our data indicate that artificial neural networks can be trained to diagnose PSL at a human expert level, based on patterns provided by ELM criteria. We suggest that this technique offers a new approach to the diagnosis of PSL.

ELM is a new approach to the diagnosis of pigmented skin lesions that holds considerable promise. It reveals a new dimension of in vivo morphology that can be used when the diagnostic criteria employed in routine visual diagnosis fail. It does not add to the diagnostic armamentarium available for unequivocal lesions, but has significant value for those equivocal, small, pigmented skin lesions that pose major diagnostic problems even for experienced clinicians. Prerequisites for a sensible approach to ELM include recognition of new morphologic ELM criteria and employment of these criteria in an analytic process called pattern analysis. As in clinical dermatology, ELM depends heavily on a learning process and, of course, on experience. ELM increases diagnostic accuracy for pigmented skin lesions in that it helps to distinguish between melanocytic and non-melanocytic pigmented lesions, and between benign and malignant growth patterns. Thus, ELM has the potential to overcome the diagnostic limitations encountered in clinical dermatology when small, early pigmented lesions are encountered that do not yet express the full complement of diagnostic features needed to arrive at a correct diagnosis. The fact that it is a noninvasive, in vivo method makes it even more attractive as a diagnostic tool in clinical practice. ELM already has proven to be of great practical value in several centers by increasing the probability that early melanoma will not be overlooked and by helping to prevent unnecessary major surgery in patients in whom a non-melanocytic or benign pigmentary lesion is suspected clinically to be a melanoma. It eventually may prove valuable for patients with dysplastic nevi by helping determine which lesions need to be removed. Of course, ELM also has limitations. It does not provide 100% diagnostic accuracy and is of little help in small lesions that are pigmented maximally and uniformly because these do not reveal the criteria necessary for ELM pattern analysis. At this stage, therefore, ELM does not replace histopathologic examination. Undoubtedly, ELM can be improved, and continued studies will reveal just how reliable the individual criteria discussed here eventually will prove to be in clinical practice. This requires continuing to accumulate and analyze data, and instituting teaching programs to familiarize dermatologists with ELM criteria and their use in pattern analysis. It is certain, however, that, just as clinicians have learned to employ the "ABCD" rules in visually recognizing and diagnosing melanoma, they will learn this new and more subtle approach to the previously unknown morphologic features that characterize benign and malignant pigmentary lesions on ELM.(ABSTRACT TRUNCATED AT 400 WORDS)

Cutaneous T-cell lymphomas (CTCL) show a wide clinical spectrum of cutaneous diseases caused by a clonal proliferation of malignant T-helper cells. In the early stages of CTCL diagnosis is challenging and may require a combination of clinical, pathological, immunomorphologic and molecular findings. The identification of early disease is crucial for the rapid implementation of adequate treatment, which may even be curative as has been reported with psoralen photochemotherapy (PUVA), total skin electron beam (TSEB) irradiation and topical chemotherapy. The combination of these treatment modalities with each other and, in addition, with management by synthetic retinoids and interferons has increased the therapeutic potential. Systemic (poly)-chemotherapy has been used so far exclusively for advanced stages of CTCL and may result in partial remission. Extracorporeal photochemotherapy (photopheresis) has been shown to be the most efficient mode of treatment for the Sézary syndrome.

Background: Epiluminescence microscopy (ELM) is a noninvasive technique by which the clinical diagnosis of pigmented skin lesions (PSL) can be improved. Many ELM criteria have been described, but their significance in the differential diagnosis of PSL has not yet been established., Objective: The purpose of this study was to determine the value of ELM criteria in the differential diagnosis of PSL., Methods: Two hundred one melanocytic PSL (61 common nevi, 60 dysplastic nevi, and 80 melanomas) were investigated with ELM for the presence of certain ELM criteria; their significance was determined by calculating the odds ratios., Results: Individual ELM criteria have different weights of significance in the differential diagnosis of melanocytic PSL. Selected patterns of ELM criteria adjusted to the distinct types of PSL considerably improve the diagnostic accuracy of melanocytic PSL., Conclusion: The prevalence of certain distinct ELM criteria in a given melanocytic PSL has statistical value in differential diagnosis.