Melanoma

NEW YORK – All patients, regardless of skin color, need to be screened for skin cancer and receive sun protection education, according to Dr. Brooke A. Jackson.

"We have done a pretty good job of relaying the skin cancer awareness/risk message to fair skin types, but we still need to work on the message to darker skin types," noted Dr. Jackson. "This includes offering skin cancer screenings to all of our patients regardless of skin color, having a [high] level of suspicion for nonhealing lesions or changing lesions in darker skin types, and discussing skin cancer risks and sun protection with our patients who have darker skin."

Dr. Jackson and her colleagues surveyed 105 dark-skinned adult patients who presented to her private practice in Chicago for a variety of reasons.

Overall, 91 patients identified themselves as black, 9 as Hispanic, 4 as Asian, and 1 as Middle Eastern, noted Dr. Jackson, clinical assistant professor of dermatology at Northwestern University in Chicago.

Of the 105 patients, 9 had a Fitzpatrick skin type of III, 29 had type IV, 64 had type V, and 3 patients had type VI.

Patients read the descriptions for several types of lesions and were asked to identify whether a particular lesion was a risk factor for skin cancer, including "dark spot with irregular border," "new mole," "nonhealing wound," "bleeding lesion," and "shiny pink bump."

Dr. Jackson found that "regardless of ethnic origin or skin type, ‘dark spot with irregular borders’ followed by ‘new mole’ were the most frequent top two choices" selected as being high risk for skin cancer.

"Shiny pink bump" was the least selected choice for recognition of skin cancer and was not selected by any respondents with skin types III and VI, she reported.

Indeed, "15 respondents, most of whom were of African ethnicity and/or had skin type V, were unaware that skin of color was at risk for developing skin cancer," noted Dr. Jackson and her colleagues.

As for skin protective behaviors, 70 of the 91 black patients reported use of sunblock or sunscreen, and 47 used protective clothing. Twenty-nine black patients practiced sun avoidance. Ten of the black patients reported that they took no precaution at all with regard to sun exposure. Similarly, among the 64 Fitzpatrick skin type V patients, 13 reported practicing no sun protection.

Dr. Jackson stated that neither she nor her colleagues had any disclosures relevant to this presentation.

NEW YORK – All patients, regardless of skin color, need to be screened for skin cancer and receive sun protection education, according to Dr. Brooke A. Jackson.

"We have done a pretty good job of relaying the skin cancer awareness/risk message to fair skin types, but we still need to work on the message to darker skin types," noted Dr. Jackson. "This includes offering skin cancer screenings to all of our patients regardless of skin color, having a [high] level of suspicion for nonhealing lesions or changing lesions in darker skin types, and discussing skin cancer risks and sun protection with our patients who have darker skin."

Dr. Jackson and her colleagues surveyed 105 dark-skinned adult patients who presented to her private practice in Chicago for a variety of reasons.

Overall, 91 patients identified themselves as black, 9 as Hispanic, 4 as Asian, and 1 as Middle Eastern, noted Dr. Jackson, clinical assistant professor of dermatology at Northwestern University in Chicago.

Of the 105 patients, 9 had a Fitzpatrick skin type of III, 29 had type IV, 64 had type V, and 3 patients had type VI.

Patients read the descriptions for several types of lesions and were asked to identify whether a particular lesion was a risk factor for skin cancer, including "dark spot with irregular border," "new mole," "nonhealing wound," "bleeding lesion," and "shiny pink bump."

Dr. Jackson found that "regardless of ethnic origin or skin type, ‘dark spot with irregular borders’ followed by ‘new mole’ were the most frequent top two choices" selected as being high risk for skin cancer.

"Shiny pink bump" was the least selected choice for recognition of skin cancer and was not selected by any respondents with skin types III and VI, she reported.

Indeed, "15 respondents, most of whom were of African ethnicity and/or had skin type V, were unaware that skin of color was at risk for developing skin cancer," noted Dr. Jackson and her colleagues.

As for skin protective behaviors, 70 of the 91 black patients reported use of sunblock or sunscreen, and 47 used protective clothing. Twenty-nine black patients practiced sun avoidance. Ten of the black patients reported that they took no precaution at all with regard to sun exposure. Similarly, among the 64 Fitzpatrick skin type V patients, 13 reported practicing no sun protection.

Dr. Jackson stated that neither she nor her colleagues had any disclosures relevant to this presentation.

NEW YORK – All patients, regardless of skin color, need to be screened for skin cancer and receive sun protection education, according to Dr. Brooke A. Jackson.

"We have done a pretty good job of relaying the skin cancer awareness/risk message to fair skin types, but we still need to work on the message to darker skin types," noted Dr. Jackson. "This includes offering skin cancer screenings to all of our patients regardless of skin color, having a [high] level of suspicion for nonhealing lesions or changing lesions in darker skin types, and discussing skin cancer risks and sun protection with our patients who have darker skin."

Dr. Jackson and her colleagues surveyed 105 dark-skinned adult patients who presented to her private practice in Chicago for a variety of reasons.

Overall, 91 patients identified themselves as black, 9 as Hispanic, 4 as Asian, and 1 as Middle Eastern, noted Dr. Jackson, clinical assistant professor of dermatology at Northwestern University in Chicago.

Of the 105 patients, 9 had a Fitzpatrick skin type of III, 29 had type IV, 64 had type V, and 3 patients had type VI.

Patients read the descriptions for several types of lesions and were asked to identify whether a particular lesion was a risk factor for skin cancer, including "dark spot with irregular border," "new mole," "nonhealing wound," "bleeding lesion," and "shiny pink bump."

Dr. Jackson found that "regardless of ethnic origin or skin type, ‘dark spot with irregular borders’ followed by ‘new mole’ were the most frequent top two choices" selected as being high risk for skin cancer.

"Shiny pink bump" was the least selected choice for recognition of skin cancer and was not selected by any respondents with skin types III and VI, she reported.

Indeed, "15 respondents, most of whom were of African ethnicity and/or had skin type V, were unaware that skin of color was at risk for developing skin cancer," noted Dr. Jackson and her colleagues.

As for skin protective behaviors, 70 of the 91 black patients reported use of sunblock or sunscreen, and 47 used protective clothing. Twenty-nine black patients practiced sun avoidance. Ten of the black patients reported that they took no precaution at all with regard to sun exposure. Similarly, among the 64 Fitzpatrick skin type V patients, 13 reported practicing no sun protection.

Dr. Jackson stated that neither she nor her colleagues had any disclosures relevant to this presentation.

Skin & Allergy News Managing Editor Amy Pfeiffer and Senior Editor Terry Rudd review hot news in dermatology with the experts in this month's Skinny Vodcast.

Highlights include Naseem Miller's interview with Dr. Thomas Rohrer on the launch of the American Academy of Dermatology's SPOT skin cancer program. We also have coverage from the AAD's 2012 volunteer event in San Diego. 

And, Dr. Susan Weinkle explains how a foot pedal-operated device can facilitate high viscosity filler injections and minimize hand fatigue from multiple injections.

Lastly, Dr. Lily Talakoub offers tips on how to answer patient questions about potential makeup toxins.

Skin & Allergy News Managing Editor Amy Pfeiffer and Senior Editor Terry Rudd review hot news in dermatology with the experts in this month's Skinny Vodcast.

Highlights include Naseem Miller's interview with Dr. Thomas Rohrer on the launch of the American Academy of Dermatology's SPOT skin cancer program. We also have coverage from the AAD's 2012 volunteer event in San Diego. 

And, Dr. Susan Weinkle explains how a foot pedal-operated device can facilitate high viscosity filler injections and minimize hand fatigue from multiple injections.

Lastly, Dr. Lily Talakoub offers tips on how to answer patient questions about potential makeup toxins.

Skin & Allergy News Managing Editor Amy Pfeiffer and Senior Editor Terry Rudd review hot news in dermatology with the experts in this month's Skinny Vodcast.

Highlights include Naseem Miller's interview with Dr. Thomas Rohrer on the launch of the American Academy of Dermatology's SPOT skin cancer program. We also have coverage from the AAD's 2012 volunteer event in San Diego. 

And, Dr. Susan Weinkle explains how a foot pedal-operated device can facilitate high viscosity filler injections and minimize hand fatigue from multiple injections.

Lastly, Dr. Lily Talakoub offers tips on how to answer patient questions about potential makeup toxins.

Among patients with stage I or II cutaneous melanoma, women have been found to have a consistent 30% advantage over men in overall survival, disease-specific survival, rate of distant metastasis, rate of lymph node metastasis, and rate of relapse, a study published online April 30 in the Journal of Clinical Oncology has shown.

"The 30% advantage extends to the whole spectrum of melanoma disease behavior," reported Dr. Arjen Joosse of Erasmus University Medical Center, Rotterdam, the Netherlands, and his associates.

Women with melanoma are known to have higher survival rates than men, but the details of the difference had never been thoroughly explored. Some experts have proposed that men have more advanced disease at diagnosis because they are less aware of melanoma, less likely to be screened, and less likely to seek medical care for a suspect lesion. Others contend that biologic differences between the sexes account for survival differences, and point to estrogen as a likely contributor.

Dr. Joosse and his colleagues examined the issue by analyzing the pooled results of four large, randomized phase III clinical trials of localized melanoma performed by the European Organisation for Research and Treatment of Cancer (EORTC). The trials, which investigated different therapies for the disease, involved detailed medical records and "meticulous" follow-up of 2,672 patients (48% men and 52% women).

"Women exhibited an independent, significant, and consistent advantage of approximately 30%" for overall survival, relapse-free survival, disease-specific survival, time to in-transit metastasis, lymph node metastasis, and distant metastasis, the investigators reported (J. Clin. Oncol. 2012 April 30 [doi:10.1200/JCO.2011.38.0584]).

This sex-based difference persisted across numerous prognostic subgroups of patients, regardless of the location of the initial lesion, Breslow thickness, the presence or absence of ulceration, and whether the patient underwent sentinel node biopsy or elective lymph node dissection. If the hypothesis about sex differences in melanoma detection, screening, and diagnostic delays were true, there should be marked differences in the discrepancy between men and women across such subgroups; but no such differences were found.

Moreover, because women showed both a longer delay before relapse and a higher cure rate, compared with men, "it seems that whatever the cause of the female advantage may be, it causes both a delay in progression and a larger subset of melanomas being cured in women, compared with men," the researchers wrote.

To explore the hypothesis that estrogen might be the source of women’s survival advantage, the investigators classified the female patients by age to approximate their menopausal status.

Postmenopausal women (defined as those aged 60 years and older) retained the 30% advantage in overall survival, relapse-free survival, time to lymph node metastasis, and time to distant metastasis, compared with premenopausal women (aged 45 and younger). The advantage for disease-specific survival declined significantly in this analysis, but that may be a chance finding because of the small sample sizes and low event rates in these subgroups.

Thus, estrogen alone cannot account for the sex-based differences in survival. Other factors that may be involved include androgen receptors in melanoma cells; differences in oxidative stress between men and women; differences between the sexes in vitamin D metabolism, because vitamin D levels appear to affect melanoma prognosis; and differences in immune homeostasis, since melanoma is thought to be immunogenic.

Unravelling the underlying cause of the survival difference between men and women could point the way to targeted therapies, the investigators noted.

They added that the 30% survival advantage in their study is consistent with a 30% advantage in 5 of the 7 published studies in the literature that included 10,000 or more patients.

The study investigators reported no relevant financial disclosures.

Among patients with stage I or II cutaneous melanoma, women have been found to have a consistent 30% advantage over men in overall survival, disease-specific survival, rate of distant metastasis, rate of lymph node metastasis, and rate of relapse, a study published online April 30 in the Journal of Clinical Oncology has shown.

"The 30% advantage extends to the whole spectrum of melanoma disease behavior," reported Dr. Arjen Joosse of Erasmus University Medical Center, Rotterdam, the Netherlands, and his associates.

Women with melanoma are known to have higher survival rates than men, but the details of the difference had never been thoroughly explored. Some experts have proposed that men have more advanced disease at diagnosis because they are less aware of melanoma, less likely to be screened, and less likely to seek medical care for a suspect lesion. Others contend that biologic differences between the sexes account for survival differences, and point to estrogen as a likely contributor.

Dr. Joosse and his colleagues examined the issue by analyzing the pooled results of four large, randomized phase III clinical trials of localized melanoma performed by the European Organisation for Research and Treatment of Cancer (EORTC). The trials, which investigated different therapies for the disease, involved detailed medical records and "meticulous" follow-up of 2,672 patients (48% men and 52% women).

"Women exhibited an independent, significant, and consistent advantage of approximately 30%" for overall survival, relapse-free survival, disease-specific survival, time to in-transit metastasis, lymph node metastasis, and distant metastasis, the investigators reported (J. Clin. Oncol. 2012 April 30 [doi:10.1200/JCO.2011.38.0584]).

This sex-based difference persisted across numerous prognostic subgroups of patients, regardless of the location of the initial lesion, Breslow thickness, the presence or absence of ulceration, and whether the patient underwent sentinel node biopsy or elective lymph node dissection. If the hypothesis about sex differences in melanoma detection, screening, and diagnostic delays were true, there should be marked differences in the discrepancy between men and women across such subgroups; but no such differences were found.

Moreover, because women showed both a longer delay before relapse and a higher cure rate, compared with men, "it seems that whatever the cause of the female advantage may be, it causes both a delay in progression and a larger subset of melanomas being cured in women, compared with men," the researchers wrote.

To explore the hypothesis that estrogen might be the source of women’s survival advantage, the investigators classified the female patients by age to approximate their menopausal status.

Postmenopausal women (defined as those aged 60 years and older) retained the 30% advantage in overall survival, relapse-free survival, time to lymph node metastasis, and time to distant metastasis, compared with premenopausal women (aged 45 and younger). The advantage for disease-specific survival declined significantly in this analysis, but that may be a chance finding because of the small sample sizes and low event rates in these subgroups.

Thus, estrogen alone cannot account for the sex-based differences in survival. Other factors that may be involved include androgen receptors in melanoma cells; differences in oxidative stress between men and women; differences between the sexes in vitamin D metabolism, because vitamin D levels appear to affect melanoma prognosis; and differences in immune homeostasis, since melanoma is thought to be immunogenic.

Unravelling the underlying cause of the survival difference between men and women could point the way to targeted therapies, the investigators noted.

They added that the 30% survival advantage in their study is consistent with a 30% advantage in 5 of the 7 published studies in the literature that included 10,000 or more patients.

The study investigators reported no relevant financial disclosures.

Among patients with stage I or II cutaneous melanoma, women have been found to have a consistent 30% advantage over men in overall survival, disease-specific survival, rate of distant metastasis, rate of lymph node metastasis, and rate of relapse, a study published online April 30 in the Journal of Clinical Oncology has shown.

"The 30% advantage extends to the whole spectrum of melanoma disease behavior," reported Dr. Arjen Joosse of Erasmus University Medical Center, Rotterdam, the Netherlands, and his associates.

Women with melanoma are known to have higher survival rates than men, but the details of the difference had never been thoroughly explored. Some experts have proposed that men have more advanced disease at diagnosis because they are less aware of melanoma, less likely to be screened, and less likely to seek medical care for a suspect lesion. Others contend that biologic differences between the sexes account for survival differences, and point to estrogen as a likely contributor.

Dr. Joosse and his colleagues examined the issue by analyzing the pooled results of four large, randomized phase III clinical trials of localized melanoma performed by the European Organisation for Research and Treatment of Cancer (EORTC). The trials, which investigated different therapies for the disease, involved detailed medical records and "meticulous" follow-up of 2,672 patients (48% men and 52% women).

"Women exhibited an independent, significant, and consistent advantage of approximately 30%" for overall survival, relapse-free survival, disease-specific survival, time to in-transit metastasis, lymph node metastasis, and distant metastasis, the investigators reported (J. Clin. Oncol. 2012 April 30 [doi:10.1200/JCO.2011.38.0584]).

This sex-based difference persisted across numerous prognostic subgroups of patients, regardless of the location of the initial lesion, Breslow thickness, the presence or absence of ulceration, and whether the patient underwent sentinel node biopsy or elective lymph node dissection. If the hypothesis about sex differences in melanoma detection, screening, and diagnostic delays were true, there should be marked differences in the discrepancy between men and women across such subgroups; but no such differences were found.

Moreover, because women showed both a longer delay before relapse and a higher cure rate, compared with men, "it seems that whatever the cause of the female advantage may be, it causes both a delay in progression and a larger subset of melanomas being cured in women, compared with men," the researchers wrote.

To explore the hypothesis that estrogen might be the source of women’s survival advantage, the investigators classified the female patients by age to approximate their menopausal status.

Postmenopausal women (defined as those aged 60 years and older) retained the 30% advantage in overall survival, relapse-free survival, time to lymph node metastasis, and time to distant metastasis, compared with premenopausal women (aged 45 and younger). The advantage for disease-specific survival declined significantly in this analysis, but that may be a chance finding because of the small sample sizes and low event rates in these subgroups.

Thus, estrogen alone cannot account for the sex-based differences in survival. Other factors that may be involved include androgen receptors in melanoma cells; differences in oxidative stress between men and women; differences between the sexes in vitamin D metabolism, because vitamin D levels appear to affect melanoma prognosis; and differences in immune homeostasis, since melanoma is thought to be immunogenic.

Unravelling the underlying cause of the survival difference between men and women could point the way to targeted therapies, the investigators noted.

They added that the 30% survival advantage in their study is consistent with a 30% advantage in 5 of the 7 published studies in the literature that included 10,000 or more patients.

The study investigators reported no relevant financial disclosures.

WAIKOLOA, HAWAII – The dermoscopic features that reliably distinguish malignant mucosal lesions are a combination of structureless areas within the lesion along with blue, gray, or white color, a multicenter study conducted by the International Dermoscopy Society has shown.

This combination of dermoscopic findings yielded 100% sensitivity for histopathologically confirmed melanoma and 93% sensitivity for any malignancy, lead investigator Dr. Andreas Blum reported at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

He noted that while the key points in dermoscopic differentiation between malignant and benign and pigmented and nonpigmented lesions of the skin, nail apparatus, and scalp are well established, the important features to look for in dermoscopic evaluation of lesions of the oral mucosa and genitalia haven’t been well characterized. That was the impetus for the international observational study.

Consensus regarding dermoscopy of mucosal lesions has lagged for a couple of reasons, explained Dr. Blum, professor of dermatology at the University of Tübingen (Germany). One is that pigmented mucosal lesions are uncommon. And another is that manipulating the dermoscope in mucosal areas can be a challenge.

The study took place at 14 specialized skin cancer clinics in 10 countries. It included 140 patients with pigmented mucosal lesions, of which 126 ultimately proved benign, while 11 were melanomas, 2 were squamous cell carcinoma in situ lesions, and 1 was a metastasis (Arch. Dermatol. 2011;147:1181-7).

The investigators scored the dermoscopic patterns they saw as dots, globules, or clods, circles, lines, or structureless using a pattern analysis method developed by Dr. Harald Kittler.

The key study finding was that in a univariate analysis, lesions that were blue, white, or gray in color under the dermoscope and that contained structureless zones had a 100% sensitivity for melanoma, a 93% sensitivity for any malignancy, and an 83% specificity for being benign.

"When you see structureless areas – and only part of the lesion needs to be structureless – with blue, gray, or white zones, then you know something has gone wrong and it’s time to do a biopsy or excision," he said.

Recognizing structureless areas might be at times a difficult call for less-experienced physicians to make, the investigators also analyzed the data based solely upon a lesion’s color. Blue, gray, or white still had a sensitivity of 100% for melanoma and 93% for any malignancy, but the specificity dropped to 64%.

"So if you’re unsure about whether you’re seeing a structureless area, based upon color only, you’ll reliably detect melanomas and other malignancies, but you’ll end up doing unnecessary biopsies for benign lesions," Dr. Blum explained.

He credited Dr. Alfred W. Kopf of New York University with a suggestion that has made dermoscopic evaluation of mucosal lesions much more practical. To avoid contaminating the lens of the dermoscope, simply wrap the head of the device in plastic food wrap that has been coated on both sides with mineral oil.

Session chair Dr. Ashfaq A. Marghoob, a coinvestigator in the international study, offered a cautionary tale. He said that he has had two teenage patients with vulvar pigmented lesions that looked clinically like a clear-cut melanoma, and dermoscopically like melanoma, and the pathology report on the biopsy specimen came back as melanoma. Yet an alert gynecologic surgical oncologist contacted him and said he thought the white area surrounding the pigmented lesion looked like lichen sclerosus et atrophicus. It turned out the surgeon was right.

"I saw the patients again, and lo and behold it was as obvious as could be. I had missed the LS & A [lichen sclerosus et atrophicus], because I was so focused on the pigmented lesion that I just hadn’t realized it was there. It turns out that if you have LS & A, you can develop pigmented lesions within it that look like melanoma clinically, that look like melanoma under dermoscopy, and look like melanoma histologically," said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

The surgery planned for one of these young patients entailed removal of the clitoral area, so timely recognition that she actually had LS & A and not melanoma spared her from a life-changing mistake.

"We’ve now been following her for 5 years, and she’s absolutely fine with no change in the pigmented lesion," he noted.

The lesson he said he’d like to share: "A vulvar melanoma in somebody under the age of 50 is almost unheard of, and I’d strongly consider LS & A instead, checking with a Wood’s light."

Neither Dr. Blum nor Dr. Marghoob reported having any relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The dermoscopic features that reliably distinguish malignant mucosal lesions are a combination of structureless areas within the lesion along with blue, gray, or white color, a multicenter study conducted by the International Dermoscopy Society has shown.

This combination of dermoscopic findings yielded 100% sensitivity for histopathologically confirmed melanoma and 93% sensitivity for any malignancy, lead investigator Dr. Andreas Blum reported at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

He noted that while the key points in dermoscopic differentiation between malignant and benign and pigmented and nonpigmented lesions of the skin, nail apparatus, and scalp are well established, the important features to look for in dermoscopic evaluation of lesions of the oral mucosa and genitalia haven’t been well characterized. That was the impetus for the international observational study.

Consensus regarding dermoscopy of mucosal lesions has lagged for a couple of reasons, explained Dr. Blum, professor of dermatology at the University of Tübingen (Germany). One is that pigmented mucosal lesions are uncommon. And another is that manipulating the dermoscope in mucosal areas can be a challenge.

The study took place at 14 specialized skin cancer clinics in 10 countries. It included 140 patients with pigmented mucosal lesions, of which 126 ultimately proved benign, while 11 were melanomas, 2 were squamous cell carcinoma in situ lesions, and 1 was a metastasis (Arch. Dermatol. 2011;147:1181-7).

The investigators scored the dermoscopic patterns they saw as dots, globules, or clods, circles, lines, or structureless using a pattern analysis method developed by Dr. Harald Kittler.

The key study finding was that in a univariate analysis, lesions that were blue, white, or gray in color under the dermoscope and that contained structureless zones had a 100% sensitivity for melanoma, a 93% sensitivity for any malignancy, and an 83% specificity for being benign.

"When you see structureless areas – and only part of the lesion needs to be structureless – with blue, gray, or white zones, then you know something has gone wrong and it’s time to do a biopsy or excision," he said.

Recognizing structureless areas might be at times a difficult call for less-experienced physicians to make, the investigators also analyzed the data based solely upon a lesion’s color. Blue, gray, or white still had a sensitivity of 100% for melanoma and 93% for any malignancy, but the specificity dropped to 64%.

"So if you’re unsure about whether you’re seeing a structureless area, based upon color only, you’ll reliably detect melanomas and other malignancies, but you’ll end up doing unnecessary biopsies for benign lesions," Dr. Blum explained.

He credited Dr. Alfred W. Kopf of New York University with a suggestion that has made dermoscopic evaluation of mucosal lesions much more practical. To avoid contaminating the lens of the dermoscope, simply wrap the head of the device in plastic food wrap that has been coated on both sides with mineral oil.

Session chair Dr. Ashfaq A. Marghoob, a coinvestigator in the international study, offered a cautionary tale. He said that he has had two teenage patients with vulvar pigmented lesions that looked clinically like a clear-cut melanoma, and dermoscopically like melanoma, and the pathology report on the biopsy specimen came back as melanoma. Yet an alert gynecologic surgical oncologist contacted him and said he thought the white area surrounding the pigmented lesion looked like lichen sclerosus et atrophicus. It turned out the surgeon was right.

"I saw the patients again, and lo and behold it was as obvious as could be. I had missed the LS & A [lichen sclerosus et atrophicus], because I was so focused on the pigmented lesion that I just hadn’t realized it was there. It turns out that if you have LS & A, you can develop pigmented lesions within it that look like melanoma clinically, that look like melanoma under dermoscopy, and look like melanoma histologically," said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

The surgery planned for one of these young patients entailed removal of the clitoral area, so timely recognition that she actually had LS & A and not melanoma spared her from a life-changing mistake.

"We’ve now been following her for 5 years, and she’s absolutely fine with no change in the pigmented lesion," he noted.

The lesson he said he’d like to share: "A vulvar melanoma in somebody under the age of 50 is almost unheard of, and I’d strongly consider LS & A instead, checking with a Wood’s light."

Neither Dr. Blum nor Dr. Marghoob reported having any relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – The dermoscopic features that reliably distinguish malignant mucosal lesions are a combination of structureless areas within the lesion along with blue, gray, or white color, a multicenter study conducted by the International Dermoscopy Society has shown.

This combination of dermoscopic findings yielded 100% sensitivity for histopathologically confirmed melanoma and 93% sensitivity for any malignancy, lead investigator Dr. Andreas Blum reported at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

He noted that while the key points in dermoscopic differentiation between malignant and benign and pigmented and nonpigmented lesions of the skin, nail apparatus, and scalp are well established, the important features to look for in dermoscopic evaluation of lesions of the oral mucosa and genitalia haven’t been well characterized. That was the impetus for the international observational study.

Consensus regarding dermoscopy of mucosal lesions has lagged for a couple of reasons, explained Dr. Blum, professor of dermatology at the University of Tübingen (Germany). One is that pigmented mucosal lesions are uncommon. And another is that manipulating the dermoscope in mucosal areas can be a challenge.

The study took place at 14 specialized skin cancer clinics in 10 countries. It included 140 patients with pigmented mucosal lesions, of which 126 ultimately proved benign, while 11 were melanomas, 2 were squamous cell carcinoma in situ lesions, and 1 was a metastasis (Arch. Dermatol. 2011;147:1181-7).

The investigators scored the dermoscopic patterns they saw as dots, globules, or clods, circles, lines, or structureless using a pattern analysis method developed by Dr. Harald Kittler.

The key study finding was that in a univariate analysis, lesions that were blue, white, or gray in color under the dermoscope and that contained structureless zones had a 100% sensitivity for melanoma, a 93% sensitivity for any malignancy, and an 83% specificity for being benign.

"When you see structureless areas – and only part of the lesion needs to be structureless – with blue, gray, or white zones, then you know something has gone wrong and it’s time to do a biopsy or excision," he said.

Recognizing structureless areas might be at times a difficult call for less-experienced physicians to make, the investigators also analyzed the data based solely upon a lesion’s color. Blue, gray, or white still had a sensitivity of 100% for melanoma and 93% for any malignancy, but the specificity dropped to 64%.

"So if you’re unsure about whether you’re seeing a structureless area, based upon color only, you’ll reliably detect melanomas and other malignancies, but you’ll end up doing unnecessary biopsies for benign lesions," Dr. Blum explained.

He credited Dr. Alfred W. Kopf of New York University with a suggestion that has made dermoscopic evaluation of mucosal lesions much more practical. To avoid contaminating the lens of the dermoscope, simply wrap the head of the device in plastic food wrap that has been coated on both sides with mineral oil.

Session chair Dr. Ashfaq A. Marghoob, a coinvestigator in the international study, offered a cautionary tale. He said that he has had two teenage patients with vulvar pigmented lesions that looked clinically like a clear-cut melanoma, and dermoscopically like melanoma, and the pathology report on the biopsy specimen came back as melanoma. Yet an alert gynecologic surgical oncologist contacted him and said he thought the white area surrounding the pigmented lesion looked like lichen sclerosus et atrophicus. It turned out the surgeon was right.

"I saw the patients again, and lo and behold it was as obvious as could be. I had missed the LS & A [lichen sclerosus et atrophicus], because I was so focused on the pigmented lesion that I just hadn’t realized it was there. It turns out that if you have LS & A, you can develop pigmented lesions within it that look like melanoma clinically, that look like melanoma under dermoscopy, and look like melanoma histologically," said Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

The surgery planned for one of these young patients entailed removal of the clitoral area, so timely recognition that she actually had LS & A and not melanoma spared her from a life-changing mistake.

"We’ve now been following her for 5 years, and she’s absolutely fine with no change in the pigmented lesion," he noted.

The lesson he said he’d like to share: "A vulvar melanoma in somebody under the age of 50 is almost unheard of, and I’d strongly consider LS & A instead, checking with a Wood’s light."

Neither Dr. Blum nor Dr. Marghoob reported having any relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Improved early detection of fast-growing, lethal melanomas will require out-of-the-box thinking, such as providing dermatoscopes for patients to use at home and educating hairdressers and other nondermatologists on how to detect melanoma.

"At least three companies are now designing dermatoscopes for patient use. Patients will be able to buy the dermatoscope at a pharmacy and do self-examination or examine their spouse. That, I think, is going to be a reality within the next 5 years," Dr. Ashfaq A. Marghoob predicted at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Photo: Dean Bertoncelj/iStockphoto

A key feature of these devices will be the capability of hooking into a smart phone for wireless transmission of suspicious images to a skin cancer expert for assessment.

Dr. Marghoob and his coworkers first proposed dermoscopy as a tool with untapped potential for skin self-examination in selected patients in an article last year (Arch. Dermatol. 2011;147:53-8).

But patient empowerment is only part of what’s needed in order to improve early detection of the fast-growing killer subtype of melanoma. Dr. Marghoob and his coworkers are now conducting a prospective study to evaluate the impact of a 20-minute education session for hair care professionals about how they can aid in detecting skin cancers on the scalp, neck, and face.

This study was a direct outgrowth of a survey the investigators conducted at a Houston convention of barbers and hairstylists. Forty-nine percent of respondents indicated they were highly receptive to participating in a skin cancer education program. During the preceding month, 37% of respondents had looked at more than half of their customers’ scalps for suspicious lesions, 29% had looked at more than half of their customers’ necks, and 15% had checked more than half of their customers’ faces (Arch. Dermatol. 2011;147:1159-65).

Melanoma of the scalp and neck accounted for 10% of all melanoma deaths in the United States from 1973 to 2003. Barbers and hairstylists are in a unique position to detect skin cancers in those locations because they typically see their customers on a regular basis, spend a fair amount of time with them at each visit, have good rapport, and often discuss health issues.

The larger goal underlying this project, Dr. Marghoob explained, is to develop a cadre of expertly trained lay community workers to examine areas of the skin that are difficult for people to see for themselves and which often go overlooked by physicians. In addition to hair professionals, other workers ideally suited to serve as lay skin cancer educators and examiners include massage therapists, manicurists, cosmetologists, and electrologists.

Dr. Marghoob has also been involved in efforts to teach dermoscopy to primary care physicians and other nondermatologist physicians, including ob.gyns., pediatricians, and plastic surgeons. Moreover, he recently conducted a study in which second-year medical students were issued dermatoscopes and trained in their use.

"We found they get better at diagnosing skin cancer and are paying more attention to the skin. All we really want them to do is really look at the skin while they’re doing a physical examination," he said.

He has also been encouraging internists and family physicians to take advantage of opportunistic skin screening situations. For example, when they’re listening to the lungs and heart with a stethoscope, he urges primary care physicians to have patients take their shirt off so they can take a close look at the truncal skin rather than simply slip the bell of the scope underneath the shirt.

Another potentially fruitful means of improving upon the gains achieved in early detection of skin cancer would be targeted screening of older men, a high-risk group for fast-growing nodular melanomas, Dr. Marghoob added.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Improved early detection of fast-growing, lethal melanomas will require out-of-the-box thinking, such as providing dermatoscopes for patients to use at home and educating hairdressers and other nondermatologists on how to detect melanoma.

"At least three companies are now designing dermatoscopes for patient use. Patients will be able to buy the dermatoscope at a pharmacy and do self-examination or examine their spouse. That, I think, is going to be a reality within the next 5 years," Dr. Ashfaq A. Marghoob predicted at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Photo: Dean Bertoncelj/iStockphoto

A key feature of these devices will be the capability of hooking into a smart phone for wireless transmission of suspicious images to a skin cancer expert for assessment.

Dr. Marghoob and his coworkers first proposed dermoscopy as a tool with untapped potential for skin self-examination in selected patients in an article last year (Arch. Dermatol. 2011;147:53-8).

But patient empowerment is only part of what’s needed in order to improve early detection of the fast-growing killer subtype of melanoma. Dr. Marghoob and his coworkers are now conducting a prospective study to evaluate the impact of a 20-minute education session for hair care professionals about how they can aid in detecting skin cancers on the scalp, neck, and face.

This study was a direct outgrowth of a survey the investigators conducted at a Houston convention of barbers and hairstylists. Forty-nine percent of respondents indicated they were highly receptive to participating in a skin cancer education program. During the preceding month, 37% of respondents had looked at more than half of their customers’ scalps for suspicious lesions, 29% had looked at more than half of their customers’ necks, and 15% had checked more than half of their customers’ faces (Arch. Dermatol. 2011;147:1159-65).

Melanoma of the scalp and neck accounted for 10% of all melanoma deaths in the United States from 1973 to 2003. Barbers and hairstylists are in a unique position to detect skin cancers in those locations because they typically see their customers on a regular basis, spend a fair amount of time with them at each visit, have good rapport, and often discuss health issues.

The larger goal underlying this project, Dr. Marghoob explained, is to develop a cadre of expertly trained lay community workers to examine areas of the skin that are difficult for people to see for themselves and which often go overlooked by physicians. In addition to hair professionals, other workers ideally suited to serve as lay skin cancer educators and examiners include massage therapists, manicurists, cosmetologists, and electrologists.

Dr. Marghoob has also been involved in efforts to teach dermoscopy to primary care physicians and other nondermatologist physicians, including ob.gyns., pediatricians, and plastic surgeons. Moreover, he recently conducted a study in which second-year medical students were issued dermatoscopes and trained in their use.

"We found they get better at diagnosing skin cancer and are paying more attention to the skin. All we really want them to do is really look at the skin while they’re doing a physical examination," he said.

He has also been encouraging internists and family physicians to take advantage of opportunistic skin screening situations. For example, when they’re listening to the lungs and heart with a stethoscope, he urges primary care physicians to have patients take their shirt off so they can take a close look at the truncal skin rather than simply slip the bell of the scope underneath the shirt.

Another potentially fruitful means of improving upon the gains achieved in early detection of skin cancer would be targeted screening of older men, a high-risk group for fast-growing nodular melanomas, Dr. Marghoob added.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Improved early detection of fast-growing, lethal melanomas will require out-of-the-box thinking, such as providing dermatoscopes for patients to use at home and educating hairdressers and other nondermatologists on how to detect melanoma.

"At least three companies are now designing dermatoscopes for patient use. Patients will be able to buy the dermatoscope at a pharmacy and do self-examination or examine their spouse. That, I think, is going to be a reality within the next 5 years," Dr. Ashfaq A. Marghoob predicted at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Photo: Dean Bertoncelj/iStockphoto

A key feature of these devices will be the capability of hooking into a smart phone for wireless transmission of suspicious images to a skin cancer expert for assessment.

Dr. Marghoob and his coworkers first proposed dermoscopy as a tool with untapped potential for skin self-examination in selected patients in an article last year (Arch. Dermatol. 2011;147:53-8).

But patient empowerment is only part of what’s needed in order to improve early detection of the fast-growing killer subtype of melanoma. Dr. Marghoob and his coworkers are now conducting a prospective study to evaluate the impact of a 20-minute education session for hair care professionals about how they can aid in detecting skin cancers on the scalp, neck, and face.

This study was a direct outgrowth of a survey the investigators conducted at a Houston convention of barbers and hairstylists. Forty-nine percent of respondents indicated they were highly receptive to participating in a skin cancer education program. During the preceding month, 37% of respondents had looked at more than half of their customers’ scalps for suspicious lesions, 29% had looked at more than half of their customers’ necks, and 15% had checked more than half of their customers’ faces (Arch. Dermatol. 2011;147:1159-65).

Melanoma of the scalp and neck accounted for 10% of all melanoma deaths in the United States from 1973 to 2003. Barbers and hairstylists are in a unique position to detect skin cancers in those locations because they typically see their customers on a regular basis, spend a fair amount of time with them at each visit, have good rapport, and often discuss health issues.

The larger goal underlying this project, Dr. Marghoob explained, is to develop a cadre of expertly trained lay community workers to examine areas of the skin that are difficult for people to see for themselves and which often go overlooked by physicians. In addition to hair professionals, other workers ideally suited to serve as lay skin cancer educators and examiners include massage therapists, manicurists, cosmetologists, and electrologists.

Dr. Marghoob has also been involved in efforts to teach dermoscopy to primary care physicians and other nondermatologist physicians, including ob.gyns., pediatricians, and plastic surgeons. Moreover, he recently conducted a study in which second-year medical students were issued dermatoscopes and trained in their use.

"We found they get better at diagnosing skin cancer and are paying more attention to the skin. All we really want them to do is really look at the skin while they’re doing a physical examination," he said.

He has also been encouraging internists and family physicians to take advantage of opportunistic skin screening situations. For example, when they’re listening to the lungs and heart with a stethoscope, he urges primary care physicians to have patients take their shirt off so they can take a close look at the truncal skin rather than simply slip the bell of the scope underneath the shirt.

Another potentially fruitful means of improving upon the gains achieved in early detection of skin cancer would be targeted screening of older men, a high-risk group for fast-growing nodular melanomas, Dr. Marghoob added.

He reported having no financial conflicts. SDEF and this news organization are owned by Elsevier.