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Background: Clinical and histopathologic assessment of pigmented skin lesions remains challenging even for experts. Differentiated and accurate noninvasive diagnostic modalities are highly desirable.Objective: We sought to provide clinicians with such a tool.Methods: A 2-gene classification method based on LINC00518 and preferentially expressed antigen in melanoma (PRAME) gene expression was evaluated and validated in 555 pigmented lesions (157 training and 398 validation samples) obtained noninvasively via adhesive patch biopsy. Results were compared with standard histopathologic assessment in lesions with a consensus diagnosis among 3 experienced dermatopathologists.Results: In 398 validation samples (87 melanomas and 311 nonmelanomas), LINC00518 and/or PRAME detection appropriately differentiated melanoma from nonmelanoma samples with a sensitivity of 91% and a specificity of 69%. We established LINC00518 and PRAME in both adhesive patch melanoma samples and underlying formalin fixed paraffin embedded (FFPE) samples of surgically excised primary melanomas and in melanoma lymph node metastases.Limitations: This technology cannot be used on mucous membranes, palms of hands, and soles of feet.Conclusions: This noninvasive 2-gene pigmented lesion assay classifies pigmented lesions into melanoma and nonmelanoma groups and may serve as a tool to help with diagnostic challenges that may be inherently linked to the visual image and pattern recognition approach. [ABSTRACT FROM AUTHOR]

Background: Shiny white streaks (SWSs) are best visualized with polarized dermoscopy and correlate with dermal fibroplasia histopathologically. SWSs have been described at higher frequencies in melanomas than in benign nevi., Objective: We assessed the diagnostic value of different patterns of SWSs and their histologic correlate in melanocytic lesions., Methods: Polarized dermoscopic images of 1507 histopathologically diagnosed melanocytic neoplasms were analyzed for presence and pattern of SWSs. Histology was also reviewed for correlation., Results: Among 1507 melanocytic neoplasms, SWSs were observed in 31 of 144 melanomas (22%) and 22 of 1363 benign neoplasms (1.6%) (P < .001). The sensitivity and specificity of SWSs for melanoma were 22% and 98%, respectively. Diffuse SWSs exhibited the greatest diagnostic value for melanoma, with sensitivity of 11.8% and specificity of 99.5%. Focal central and peripheral SWSs were comparable in diagnostic significance. The presence of SWSs was highly uncommon in dysplastic nevi, whereas in certain benign subgroups of nevi such as Spitz nevi and atypical genital special site nevi, SWSs were not uncommon. Diffuse SWSs correlated with greater breadth of deep fibroplasia than focal SWSs (P = .009), and SWSs correlated with greater Breslow depth among melanomas (P = .007)., Limitations: This study was retrospective., Conclusion: Polarized dermoscopy is a valuable diagnostic tool in the identification of SWSs, a feature that is highly specific for melanoma., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Controversy exists about an association between angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), and thiazides (TZs) and the risk of malignant melanoma (MM), and non-melanoma skin cancer-basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)., Objective: The aim of this study was to determine if an association exists for ACEI, ARB, or TZ exposure and skin cancers., Methods: This was a matched cohort study using a large electronic medical records repository, the Northwestern Medicine Enterprise Data Warehouse (NMEDW). The exposed population consisted of patients with a documented order for an ACEI, ARB, or TZ with no prior history of skin cancer. The control population consisted of matched patients without documented exposure to ACEI, ARB, or TZ and no previous skin cancer. Incident MM, BCC, or SCC diagnosis by ICD-9 codes was recorded. Odds ratios (ORs) were obtained by using logistic regression analyses., Results: Among the 27,134 patients exposed to an ACEI, 87 MM, 533 BCC, and 182 SCC were detected. Among the 13,818 patients exposed to an ARB, 96 MM, 283 BCC, and 106 SCC were detected. Among the 15,166 patients exposed to a TZ, 99 MM, 262 BCC, and 130 SCC were detected. Significant associations using ORs from logistic regression were found for MM and TZs (OR 1.82; 95% confidence interval [CI] 1.01-3.82); BCC and ARBs (OR 2.86; 95% CI 2.13-3.83), ACEIs (OR 2.23; 95% CI 1.78-2.81) and TZs (OR 2.11; 95% CI 1.60-2.79); SCC and ARBs (OR 2.22; 95% CI 1.37-3.61), ACEIs (OR 1.94; 95% CI 1.37-2.76), and TZs (OR 4.11; 95% CI 2.66-6.35)., Conclusions: A safety signal for ACEIs, ARBs, and TZs and BCC and SCC, as well as for TZs and MM, was detected. An increased awareness and education, especially for those who are at high risk for skin cancer, are warranted for patients and healthcare providers. Further exploration of such associations for these commonly used drug classes is warranted.

Background: Clinical and histopathologic assessment of pigmented skin lesions remains challenging even for experts. Differentiated and accurate noninvasive diagnostic modalities are highly desirable., Objective: We sought to provide clinicians with such a tool., Methods: A 2-gene classification method based on LINC00518 and preferentially expressed antigen in melanoma (PRAME) gene expression was evaluated and validated in 555 pigmented lesions (157 training and 398 validation samples) obtained noninvasively via adhesive patch biopsy. Results were compared with standard histopathologic assessment in lesions with a consensus diagnosis among 3 experienced dermatopathologists., Results: In 398 validation samples (87 melanomas and 311 nonmelanomas), LINC00518 and/or PRAME detection appropriately differentiated melanoma from nonmelanoma samples with a sensitivity of 91% and a specificity of 69%. We established LINC00518 and PRAME in both adhesive patch melanoma samples and underlying formalin fixed paraffin embedded (FFPE) samples of surgically excised primary melanomas and in melanoma lymph node metastases., Limitations: This technology cannot be used on mucous membranes, palms of hands, and soles of feet., Conclusions: This noninvasive 2-gene pigmented lesion assay classifies pigmented lesions into melanoma and nonmelanoma groups and may serve as a tool to help with diagnostic challenges that may be inherently linked to the visual image and pattern recognition approach., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: To increase adherence to cancer management guidelines, the Commission on Cancer (CoC) developed and approved five melanoma quality measures in 2015. Our objectives were to evaluate formally the national performance of these melanoma measures and to examine patient, tumor, and hospital characteristics associated with adherence., Methods: From the National Cancer Data Base (2012), patients with invasive, nonmetastatic melanoma were identified. Inclusion and exclusion criteria were based on the CoC definition for each measure. Patient-level and hospital-level adherence rates were calculated for the five measures. A hospital was deemed "compliant" if it met the CoC standard, which requires 80 % of patients to receive the measure-specific recommended care. Patient, tumor, and hospital characteristics potentially associated with higher likelihood of adherence at the patient-level were estimated using hierarchical random-effects logistic regression models., Results: A total of 31,598 patients from 1343 hospitals were examined. Patient-level adherence rates varied from 31.6 % (Measure 5: ≥10 axillary lymph nodes removed/examined) to 72.6 % (Measure 1: sentinel lymph node biopsy (SLNB) appropriateness measure). Hospital-level adherence rates, ranged from 19.3 % of hospitals (N = 538 hospitals for Measure 5) to 44.8 % of hospitals (N = 1090 hospitals for Measure 3: completion lymph node dissection after positive SLNB). No hospital-level factors (e.g., teaching status) were consistently associated with better adherence., Conclusions: National adherence rates to the five new CoC melanoma quality metrics are low, and most hospitals would not meet the CoC requirement of 80 % adherence. Feedback for performance of these measures to hospitals, decisions support tools, and educational initiatives are needed to improve guideline adherence.

Background: Nevi of special sites display aberrant clinical and histologic features that can be difficult to distinguish from melanoma, leading to unnecessarily high rates of excision with poor cosmetic or functional results. Dermoscopy can improve clinical assessment of melanocytic lesions by visualizing morphologic structures beyond the epidermis., Objective: We sought to assess the value of specific dermoscopic features for diagnosing melanocytic neoplasms arising on the breast area in females., Methods: In this retrospective cohort study, we collected clinical and dermoscopic information for 104 nevi and 13 melanomas removed from the breast, chest, and areola, and evaluated the diagnostic performance of each dermoscopic feature., Results: Melanomas from the breast area were larger (P = .0175) than nevi and occurred in older women (P = .0117). Irregular blotches, nonuniform radial streaks, blue-gray veil, and regression were highly specific for melanoma, whereas atypical network and irregular dots and globules had low to moderate specificity., Limitations: This study was retrospective with a small sample size., Conclusion: Compared to melanocytic neoplasms from other sites, atypical network and irregular dots and globules were poor indicators for breast melanoma. Irregular blotches, nonuniform radial streaks, blue-gray veil, and regression were highly specific and should heighten clinical suspicion for melanoma arising on the breast., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Dermoscopy allows for visualization of morphologic structures beyond the epidermis, including features that may indicate early malignant transformation. However, dermoscopic features are rarely considered during routine histologic sectioning, and areas of clinical concern may be missed during microscopic evaluation., Objective: We assessed the diagnostic impact of a dermoscopy-guided micropunch score for the evaluation of melanocytic lesions., Methods: In this case-control study, we evaluated 150 scored melanocytic lesions. Original tissue specimens were reprocessed to create a control group, in which a new score was introduced elsewhere in the lesion to guide an alternative plane of section. Slides were reviewed in a randomized, double-blinded manner to assess histologic features and render a diagnosis. Dermoscopy was also reviewed., Results: The proportion of cases with a higher grade in the original, dermoscopy-guided section was statistically significant. Four invasive melanomas were exclusively identified using the scoring protocol. The presence of regression structures, negative pigment network, radial streaming or pseudopods, and irregular blotches were highly specific for a higher diagnostic grade., Limitations: This study is retrospective and reprocessing tissue does not perfectly mimic routine sectioning., Conclusion: Dermoscopy can identify important, histologically high-grade areas, and this information can be used to optimize the sectioning of melanocytic neoplasms., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The influence of pregnancy on the development, progression, and prognosis of melanoma is controversial., Objective: We sought to compare clinical characteristics, histologic features, and proliferative activity in pregnancy-associated melanoma (PAM) and melanoma in nonpregnant women of reproductive age (non-PAM)., Methods: In this retrospective cohort study, we reviewed medical records and pathology reports from women given a diagnosis of melanoma between 2006 and 2015. We also examined tumor proliferation rates using mitotic count and 2 immunohistochemical markers of proliferation, phosphohistone H3 and Ki-67., Results: In 50 PAM and 122 non-PAM cases, a diagnosis of melanoma in situ was associated with PAM. Among invasive melanomas, there was no difference in proliferative activity between groups. Pregnancy status was also not associated with age at diagnosis, tumor site, Breslow depth, Clark level, ulceration, or overall stage., Limitations: This was a retrospective study with a small sample size of mostly patients with early-stage melanoma., Conclusions: In our study of primarily early-stage melanoma, pregnancy did not have a significant impact on tumor proliferation. Particularly for patients given a diagnosis of stage I melanoma who are undergoing close surveillance, a history of PAM should not outweigh traditional factors, such as advanced maternal age, in planning future pregnancies., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Importance: Early detection of melanoma may improve survival. The present study continued research establishing that in-person training on skin self-examinations (SSEs) was significantly enhanced when delivered to patients with their partners present instead of to patients alone., Objective: To examine 3 alternative SSE training approaches that included partners compared with a treatment-as-usual control condition., Design, Setting, and Participants: A randomized clinical trial with 4- and 12-month follow-up visits was conducted at the clinical offices in the ambulatory care area of a hospital. The evaluable population included 494 patients with stage 0 to IIB melanoma and their skin check partners drawn from an electronic medical record melanoma registry and advertisements in large regional newspapers. The study was conducted from June 6, 2011, to April 14, 2014, and analysis was performed between December 4 and December 11, 2014., Interventions: Pairs of patients and their partners were randomly assigned to (1) in-person intervention, (2) take-home booklet intervention, and (3) treatment-as-usual controls. An additional subgroup of patients received an electronic interactive tablet personal computer intervention. The MoleScore content was comparable across formats and consisted of demonstrations of the ABCDE (assess border, color, diameter, and evolution of pigmented lesions) rule and skills training., Main Outcomes and Measures: Outcomes were self-reported SSE of the total body as well as easy-to-see and difficult-to-see regions at baseline, 4 months, and 12 months., Results: No significant differences in SSEs were observed between the 3 intervention conditions on all of the body areas; results for all 3 intervention conditions were significantly higher than for controls at 4- and 12-month follow-ups (all P < .05). Mean (SD) body areas examined by control pairs (n = 99) at 4 months (0.98 [1.17]) and 12 months (1.82 [1.43]) were significantly less compared with examination by pairs participating in all interventions at 4 months (workbook [n = 159], 2.68 [1.19]; in-person [n = 165], 2.66 [1.11]; and tablet [n = 71], 2.53 [1.17]) and at 12 months (workbook, 2.53 [1.25]; in-person, 2.59 [1.30]; and tablet, 2.34 [1.37]) (F6,674 = 15.60; P < .001; η2 = 0.12)., Conclusions and Relevance: The findings of the research support the sustainability and efficacy at 12 months of partner-assisted SSE interventions for early detection targeting individuals with a history of melanoma., Trial Registration: clinicaltrials.gov Identifier: NCT01432860.

Background: Early detection of melanoma improves survival. Since many melanoma patients and their spouses seek the care of a physician after discovering their melanoma, an ongoing study will determine the efficacy of teaching at-risk melanoma patients and their skin check partner how to conduct skin self-examinations (SSEs). Internet-based health behavior interventions have proven efficacious in creating behavior change in patients to better prevent, detect, or cope with their health issues. The efficacy of electronic interactive SSE educational intervention provided on a tablet device has not previously been determined., Objective: The electronic interactive educational intervention was created to develop a scalable, effective intervention to enhance performance and accuracy of SSE among those at-risk to develop melanoma. The intervention in the office was conducted using one of the following three methods: (1) in-person through a facilitator, (2) with a paper workbook, or (3) with a tablet device used in the clinical office. Differences related to method of delivery were elucidated by having the melanoma patient and their skin check partner provide a self-report of their confidence in performing SSE and take a knowledge-based test immediately after receiving the intervention., Methods: The three interventions used 9 of the 26 behavioral change techniques defined by Abraham and Michie to promote planning of monthly SSE, encourage performing SSE, and reinforce self-efficacy by praising correct responses to knowledge-based decision making and offering helpful suggestions to improve performance. In creating the electronic interactive SSE educational intervention, the educational content was taken directly from both the scripted in-person presentation delivered with Microsoft PowerPoint by a trained facilitator and the paper workbook training arms of the study. Enrollment totaled 500 pairs (melanoma patient and their SSE partner) with randomization of 165 pairs to the in-person, 165 pairs to the workbook, and 70 pairs to electronic interactive SSE educational intervention., Results: The demographic survey data showed no significant mean differences between groups in age, education, or income. The tablet usability survey given to the first 30 tablet pairs found that, overall, participants found the electronic interactive intervention easy to use and that the video of the doctor-patient-partner dialogue accompanying the dermatologist's examination was particularly helpful in understanding what they were asked to do for the study. The interactive group proved to be just as good as the workbook group in self-confidence of scoring moles, and just as good as both the workbook and the in-person intervention groups in self-confidence of monitoring their moles. While the in-person intervention performed significantly better on a skill-based quiz, the electronic interactive group performed significantly better than the workbook group. The electronic interactive and in-person interventions were more efficient (30 minutes), while the workbook took longer (45 minutes)., Conclusions: This study suggests that an electronic interactive intervention can deliver skills training comparable to other training methods, and the experience can be accommodated during the customary outpatient office visit with the physician. Further testing of the electronic interactive intervention's role in the anxiety of the pair and pair-discovered melanomas upon self-screening will elucidate the impact of these tools on outcomes in at-risk patient populations., Trial Registration: ClinicalTrials.gov NCT01013844; http://clinicaltrials.gov/show/NCT01013844 (Archived by WebCite at http://www.webcitation.org/6LvGGSTKK).

Background: The 2009 American Joint Committee on Cancer criteria for thin cutaneous melanomas recommend staging sentinel lymph node (SLN) biopsy (SLNB) for select stage IB tumors. SLNB in this population remains controversial because of low rates of node positivity and inconsistent prognostic parameters., Objective: The purpose of this study was to examine the association between multiple clinicopathologic features and SLNB result, and clinical outcome., Methods: Clinical and pathologic parameters from patients with melanomas less than or equal to 1.00 mm receiving wide local excision with SLNB at our institution from 2001 through 2010 were recorded. Analysis for any statistically significant relationships between recorded parameters and SLN results and outcome were performed., Results: A total of 189 cases yielded 3 positive SLNBs (1.6%). Disease progression occurred in 6 cases (3.2%). Positive SLNB predicted distant metastasis and death from disease (P = .0017). Mitotic rate was not associated with a positive SLNB result., Limitations: The follow-up time for this study was limited (mean = 40.7 months)., Conclusion: Our data confirm a statistically significant relationship between SLNB result and likelihood for distant metastasis in thin melanoma. There was a trend for a relationship between mitotic rate and clinical outcome. This relationship reached statistical significance at a mitotic rate of greater than 3 mitoses/mm(2)., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

By examining differences between patients who enroll or decline to enroll in a partner-based study, future research can benefit and adapt recruitment strategies to reduce sampling biases. This study examined differences between melanoma patients' who either declined or enrolled in an intervention aimed at increasing skin self-examination (SSE) with partner assistance. Specifically, differences were assessed for gender, age, perception of likelihood of getting another melanoma, benefits of early detection, and severity of the disease. Additionally, reasons for declining were examined. Among 368 melanoma patients interviewed during their appointment with the treating physician, 187 enrolled in the study and 181 declined to participate. No significant age or gender differences between enrolled and declined patients were observed. However, enrolled participants had significantly higher reports on the likelihood of getting another melanoma, severity of melanoma, and early detection as being beneficial (p<0.001). Among those declining to participate, males reported being "too busy and can't make follow-up appointments" whereas females reported their "partner won't assist". Results indicate perceptions of the benefits of early detection, the severity of melanoma, and patients' increased risk of developing a melanoma may have influenced patients' decision to participate. Future studies may benefit by highlighting these topics in order to motivate more patients to participant in partner studies.

Importance: Lack of training hampers melanoma recognition by physicians., Objective: To evaluate a melanoma simulation model to teach visual assessment and counseling skills., Design and Setting: Simulation model study in an academic research setting., Participants: A convenience sample of third-year medical students was randomly assigned to receive the intervention before or after a standardized patient., Intervention: During the primary care clerkship, medical students participated in melanoma skills training using 2 simulation models replicating melanomas and abnormal or benign nevi. Scoring threshold rules for visual assessment and management of pigmented lesions and videos of patient counseling were provided., Main Outcome Measures: Identifying a melanoma moulage and counseling the standardized patient. Secondary measures were preintervention and 2-week postintervention knowledge, attitudes about and confidence in their ability to perform opportunistic surveillance and counseling, as well as identification on the model of clinically suspicious pigmented lesions, lesions needing a biopsy, and lesions to be monitored for change. RESULTS Among 74 students, confidence in their ability to perform opportunistic surveillance improved significantly after skills training (P < .05, χ2 test). Monitoring clinically suspicious lesions for change decreased from 16% (12 of 74) to 3% (2 of 74) and performing a biopsy increased from 80% (59 of 74) to 96% (71 of 74), monitoring benign lesions for change decreased from 43% (32 of 74) to 3% (2 of 74), and biopsying melanoma in situ increased from 10% (7 of 74) to 26% (20 of 74) (P < .05 for all, χ2 test). Detection of the melanoma moulage on the standardized patient occurred more often by trained students (P < .05, χ2 test)., Conclusion and Relevance: A 1-hour melanoma simulation education and skills training experience improved performance of opportunistic surveillance, management, and patient counseling by third-year medical students., Trial Registration: clinicaltrials.gov Identifier: NCT01191294.

The NCCN Guidelines for Melanoma provide multidisciplinary recommendations on the clinical management of patients with melanoma. This NCCN Guidelines Insights report highlights notable recent updates. Foremost of these is the exciting addition of the novel agents ipilimumab and vemurafenib for treatment of advanced melanoma. The NCCN panel also included imatinib as a treatment for KIT-mutated tumors and pegylated interferon alfa-2b as an option for adjuvant therapy. Also important are revisions to the initial stratification of early-stage lesions based on the risk of sentinel lymph node metastases, and revised recommendations on the use of sentinel lymph node biopsy for low-risk groups. Finally, the NCCN panel reached clinical consensus on clarifying the role of imaging in the workup of patients with melanoma.

Introduction: The method used to create a melanoma trainer using simulated back skin is presented. The trainer is intended to be used to teach medical students to identify benign and malignant cutaneous pigmented lesions., Methods: Non-Hispanic and Hispanic white melanoma trainers were created using flexible polyurethane foam and pigmented silicone rubber. The models were reviewed by board-certified dermatologists and dermatology residents to determine the reliability and fidelity of the models., Results: The models were deemed an accurate representation of the skin of human backs containing multiple normal nevi and clinically suspicious pigmented lesions, which were melanomas. Among 33 dermatologists and dermatology residents, there was good reliability for all clinically suspicious lesions (κ = 0.64), excellent reliability for melanomas (κ = 0.97), and excellent reliability for selecting melanomas for biopsy (κ = 0.96). Reliability in selecting lesions to monitor for change varied depending on the physicians preference to perform biopsy on all melanomas and follow all other clinically suspicious lesions (κ = 0.86) or to perform biopsy on all melanomas and 1 other abnormal nevus and monitor all other abnormal lesions (κ = 0.61)., Conclusions: The melanoma trainer using simulated back skin is a reliable model that can be stored and used frequently over a long period. The trainer will allow students to assess a range of pigmented lesions that would not be found on 1 patient.

Background: Early diagnosis of melanoma remains of paramount importance, because it has been widely demonstrated that survival is strongly related to Breslow thickness. Several studies have shown that dermatoscopy improves accuracy in the diagnosis of melanoma. Although histopathology is considered the gold standard to differentiate melanoma from nevi, there are some cases of melanoma in which the histopathologic features are less than definitive. It has also been demonstrated that fluorescence in situ hybridization can be used to differentiate melanomas from nevi based on chromosomal copy number aberrations., Objective: In this study we present a case series to demonstrate the value of combining fluorescence in situ hybridization and dermatoscopy/clinical history to enhance diagnostic capability for selected cases of early melanoma., Methods: Cases were identified that had dermatoscopic findings or clinical history highly suggestive of melanoma and fluorescence in situ hybridization evaluation positive for melanoma, but histopathologic features that were less than definitive. Two dermatopathologists performed independent histologic analysis of specimens and two dermatologists experienced in dermatoscopy reviewed dermatoscopic and clinical data., Results: Nine cases meeting inclusion criteria were identified. In 6 cases the histologic differential diagnosis was dysplastic nevus versus early melanoma whereas in 3 cases the differential diagnosis included Spitz nevus versus early melanoma., Limitations: Limitations of this study include restrictive inclusion criteria and study design restricted to a case series., Conclusion: This exploratory study demonstrates that in a subset of early melanoma cases, combining multiple diagnostic modalities such as dermatoscopy and molecular techniques with histology enhances detection of early melanoma., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Purpose: The objective was to identify first-year physician assistant (PA) students' and third-year medical students' knowledge, attitudes, and behaviors about melanoma and to assess an educational intervention., Methods: Thirty first-year PA students and 29 third-year medical students (M3) at Northwestern University completed a questionnaire on participants' views of barriers and facilitators to performing melanoma screening. The students were given a pretest with a melanoma education model trainer to identify suspicious lesions, and following an educational intervention, students were given a posttest model trainer assessment., Results: Apart from time constraints (87% PA; 79% M3) and comorbidities (53% PA; 57% M3), lack of training was a frequently reported barrier to performing opportunistic surveillance (27% PA; 31% M3). Commonly reported facilitators included identification of patients at high risk for developing melanoma (60% PA; 69% M3) and skin-examination training to recognize melanoma (67% PA; 55% M3). With the melanoma trainer pretest, 35% of PA students and 27% of M3 students identified all of the melanomas (P = .61). Following educational intervention, 67% of PA students and 10% of M3 students identified all of the melanomas (P<.01). PA student identification of melanoma significantly increased from pretest to posttest (P = .035), while M3 decreased, but not appreciably (P = .063)., Conclusions: Education in melanoma detection may enhance the students' cognitive and technical skills necessary to perform accurate opportunistic surveillance. Although PA and medical students reported the same significant barriers and facilitators to performing skin exams, there was a difference in implementation of skills and in the management decisions.

Objective: To demonstrate the safety and effectiveness of MelaFind, a noninvasive and objective computer-vision system designed to aid in detection of early pigmented cutaneous melanoma., Design: A prospective, multicenter, blinded study. The diagnostic performance of MelaFind and of study clinicians was evaluated using the histologic reference standard. Standard images and patient information for a subset of 50 randomly selected lesions (25 melanomas) were used in a reader study of 39 independent dermatologists to estimate clinicians' biopsy sensitivity to melanoma., Setting: Three academic and 4 community practices in the United States with expertise in management of pigmented skin lesions., Patients: A total of 1383 patients with 1831 lesions enrolled from January 2007 to July 2008; 1632 lesions (including 127 melanomas-45% in situ-with median Breslow thickness of invasive lesions, 0.36 mm) were eligible and evaluable for the study end points., Main Outcome Measures: Sensitivity of MelaFind; specificities and biopsy ratios for MelaFind and the study investigators; and biopsy sensitivities of independent dermatologists in the reader study., Results: The measured sensitivity of MelaFind was 98.4% (125 of 127 melanomas) with a 95% lower confidence bound at 95.6% and a biopsy ratio of 10.8:1; the average biopsy sensitivity of dermatologists was 78% in the reader study. Including borderline lesions (high-grade dysplastic nevi, atypical melanocytic proliferations, or hyperplasias), MelaFind's sensitivity was 98.3% (172 of 175), with a biopsy ratio of 7.6:1. On lesions biopsied mostly to rule out melanoma, MelaFind's average specificity (9.9%) was superior to that of clinicians (3.7%) (P=.02)., Conclusion: MelaFind is a safe and effective tool to assist in the evaluation of pigmented skin lesions., Trial Registration: clinicaltrials.gov Identifier: NCT00434057., (©2011 American Medical Association. All rights reserved.)

Background: The occurrence of multiple Spitz nevi is rare, especially the disseminated variant. Multiple Spitz nevi may be confused with, and must be differentiated from, primary spitzoid melanoma and cutaneous melanoma metastases. Over the past decade, fluorescence in situ hybridization (FISH) has emerged as a tool for studying melanocytic neoplasms, helping to differentiate between melanoma and benign melanocytic nevi. We describe 2 cases of patients with multiple Spitz nevi and their FISH results., Observations: One case of disseminated Spitz nevi, in a 17-year-old female, showed balanced tetraploidy using FISH, while the other case, in a 51-year-old female with multiple Spitz nevi, showed normal diploid cells without significant gains or losses in chromosomes 6 or 11., Conclusions: Patients may present with multiple, even disseminated, Spitz nevi. This phenotype should not be confused with melanoma and/or cutaneous metastasis. The use of FISH studies in context with careful correlation of clinical features and dermoscopic and histologic findings can assist in the diagnostic workup., (©2011 American Medical Association. All rights reserved.)

Background and Objective: Melanoma is the most serious form of skin cancer and often appears as an evolving multicolored skin growth. It is well documented that pre-existing atypical or dysplastic nevi can evolve into a melanoma. The development of an in vivo imaging system to characterize benign and malignant nevi has been emphasized to aid in early detection of melanoma. The goal of this study is to utilize a novel Stokes polarimetry imaging (SPI) system for the characterization of pigmented lesions, and to evaluate the SPI system in comparison to dermoscopy and histology images., Study Design/materials and Methods: Linearly polarized light with varying incident polarization angles (IPA) illuminated various types of pigmented lesions. The melanocytic nesting patterns of pigmented lesions were characterized by constructing the degree-of-linear-polarization (DOLP) image map with comparison to dermoscopy and histology. The incident polarized light was filtered by visible filters for spectral imaging and incident deeply penetrating red light was used to correlate the SPI image with histopathological examination., Results: The DOLP images with varying IPA at different visible wavelengths were used to characterize various kinds of pigmented lesions by showing subsurface melanocytic nesting distribution as well as morphological information with better resolution and contrast. In correlation with dermoscopy and histology, various defining features such as compound, junctional, lentiginous, reticular, globular patterns of melanocytic nests were identified., Conclusion: When imaging pigmented melanocytic lesions, the SPI system with varying IPA at the red light wavelength can better define the melanocytic nesting patterns in both the dermal epidermal junction and the dermis. The SPI system has the potential to be an effective in vivo method of detecting pre-malignant nevi and melanoma.

Objective: To ascertain whether subcuticular epidermal closures of elliptical excisions of the trunk and extremities result in better functional and cosmetic outcomes than simple running epidermal closures of the same sites., Design: Randomized controlled trial, with allocation of epidermal closure of elliptical excisions to 4 arms, including 1 control arm (simple running polypropylene sutures removed after 14 days) and 3 experimental arms (subcuticular running polypropylene sutures removed after 14 days, subcuticular running polypropylene sutures left in place, and subcuticular running polyglactin 910 sutures left in place). All experimental interventions were preceded by deep dermal closure with simple interrupted polyglactin 910 sutures. Interventions were delivered by 3 surgeons, who underwent 2 training sessions to minimize intersurgeon technique variability., Setting: Institutional referral practice providing ambulatory care in an urban environment., Patients: A consecutive sample of 36 adult patients (ages 18-65 years), each referred for concurrent elliptical excision of at least 2 clinically atypical nevi of the trunk and/or extremity, were included in the study., Main Outcome Measures: Primary outcome measures obtained at 3 and 9 months included scar width in millimeters and blinded observer ordinal scale assessment of overall scar appearance. Secondary outcome measures included ratings on the standardized Vancouver Scar Scale and the Hollander Scar Scale; an additional nonstandard item was added to assess pruritus., Results: No difference among groups was found in scar width at 3 or 9 months. Differences among groups were detected in overall scar appearance (3 months, P<.001; 9 months, P<.001), vascularity (3 months, P = .001; 9 months, P<.001), excessive distortion (3 months, P = .04; 9 months, P = .02), contour irregularity (3 months, P<.001), and edge inversion (3 months, P = .01). The best overall appearance was with a subcuticular running polyglactin 910 suture left in place, and the next best was with a subcuticular running polypropylene suture left in place; differences across groups persisted but decreased in intensity at 9 months. A secondary analysis that matched high-tension anatomic sites (back and lower leg), and high and moderate tension sites (also chest and shoulder) yielded the same main effects and mostly the same results in pairwise comparisons., Conclusion: While scar width does not appear to vary significantly based on choice of epidermal closure, bilayered closures of the trunk and extremity have better overall appearance and less associated erythema at 3 and 9 months after surgery with the use of a subcuticular running polyglactin 910 suture left in place.