Melanoma

Reflectance confocal microscopy (RCM) enables in vivo imaging of human skin at a quasi histologic resolution. The black-and-white RCM images show horizontal sections of the skin, at a maximum depth of 350 m. To date, the RCM features of a significant number of skin conditions have been described. The main focus of the research community investigating RCM, however, lies on describing and diagnosing melanocytic skin lesions. Taking into account all RCM studies dealing with diagnostic accuracy in melanocytic skin lesions, sensitivity and specificity of approximately 90% and 86% could be found. Improvement of diagnostic accuracy, improved assessment of dermoscopic-histologic correlation, in vivo biopsy side selection, surgical margin assessment, and response control of conservative therapies in skin diseases are some of the major advantages of this novel imaging method. Additionally, RCM holds inherent potential for teledermatologic application and automated image analyzing. This article describes morphologic features of diverse skin lesions and features of “normal skin,” summarizes diagnostic advances of RCM, compares studies dealing with diagnostic applicability, and discusses further research goals of this exciting new imaging technique.

*For a PDF of the full article, click on the link to the left of this introduction.

Reflectance confocal microscopy (RCM) enables in vivo imaging of human skin at a quasi histologic resolution. The black-and-white RCM images show horizontal sections of the skin, at a maximum depth of 350 m. To date, the RCM features of a significant number of skin conditions have been described. The main focus of the research community investigating RCM, however, lies on describing and diagnosing melanocytic skin lesions. Taking into account all RCM studies dealing with diagnostic accuracy in melanocytic skin lesions, sensitivity and specificity of approximately 90% and 86% could be found. Improvement of diagnostic accuracy, improved assessment of dermoscopic-histologic correlation, in vivo biopsy side selection, surgical margin assessment, and response control of conservative therapies in skin diseases are some of the major advantages of this novel imaging method. Additionally, RCM holds inherent potential for teledermatologic application and automated image analyzing. This article describes morphologic features of diverse skin lesions and features of “normal skin,” summarizes diagnostic advances of RCM, compares studies dealing with diagnostic applicability, and discusses further research goals of this exciting new imaging technique.

*For a PDF of the full article, click on the link to the left of this introduction.

Reflectance confocal microscopy (RCM) enables in vivo imaging of human skin at a quasi histologic resolution. The black-and-white RCM images show horizontal sections of the skin, at a maximum depth of 350 m. To date, the RCM features of a significant number of skin conditions have been described. The main focus of the research community investigating RCM, however, lies on describing and diagnosing melanocytic skin lesions. Taking into account all RCM studies dealing with diagnostic accuracy in melanocytic skin lesions, sensitivity and specificity of approximately 90% and 86% could be found. Improvement of diagnostic accuracy, improved assessment of dermoscopic-histologic correlation, in vivo biopsy side selection, surgical margin assessment, and response control of conservative therapies in skin diseases are some of the major advantages of this novel imaging method. Additionally, RCM holds inherent potential for teledermatologic application and automated image analyzing. This article describes morphologic features of diverse skin lesions and features of “normal skin,” summarizes diagnostic advances of RCM, compares studies dealing with diagnostic applicability, and discusses further research goals of this exciting new imaging technique.

*For a PDF of the full article, click on the link to the left of this introduction.

Reflectance confocal microscopy (RCM) allows noninvasive imaging of the epidermis and superficial dermis. Like dermoscopy, RCM acquires images in the horizontal plane (en face), allowing assessment of tissue pathology underlying dermoscopic structures of interest at a cellular-level resolution. Thus, clinicians using dermoscopy may find RCM to be particularly useful. Our aim was to show the value of RCM for diagnosis and management decisions related to pigmented and nonpigmented skin neoplasms seen in daily practice. Six cases of clinically and dermoscopically equivocal skin lesions, for which RCM facilitated making the correct diagnosis, are presented. Final diagnoses were made based on histopathologic analysis. Three flat pigmented skin lesions with dermoscopic signs of regression showed distinct RCM features that allowed their correct classification as pigmented basal cell carcinoma, pigmented actinic keratosis, and melanoma on sundamaged skin. A flat nonpigmented skin lesion on the face, which did not show distinct clinical or dermoscopic features, was correctly diagnosed as basal cell carcinoma based on RCM findings. In addition, the response of a pigmented actinic keratosis and a melanoma in situ on sun-damaged skin to noninvasive topical treatment was monitored using RCM. RCM is a promising and practical imaging tool for the diagnosis and follow-up of pigmented and nonpigmented skin lesions. 

*For a PDF of the full article, click on the link to the left of this introduction.

Reflectance confocal microscopy (RCM) allows noninvasive imaging of the epidermis and superficial dermis. Like dermoscopy, RCM acquires images in the horizontal plane (en face), allowing assessment of tissue pathology underlying dermoscopic structures of interest at a cellular-level resolution. Thus, clinicians using dermoscopy may find RCM to be particularly useful. Our aim was to show the value of RCM for diagnosis and management decisions related to pigmented and nonpigmented skin neoplasms seen in daily practice. Six cases of clinically and dermoscopically equivocal skin lesions, for which RCM facilitated making the correct diagnosis, are presented. Final diagnoses were made based on histopathologic analysis. Three flat pigmented skin lesions with dermoscopic signs of regression showed distinct RCM features that allowed their correct classification as pigmented basal cell carcinoma, pigmented actinic keratosis, and melanoma on sundamaged skin. A flat nonpigmented skin lesion on the face, which did not show distinct clinical or dermoscopic features, was correctly diagnosed as basal cell carcinoma based on RCM findings. In addition, the response of a pigmented actinic keratosis and a melanoma in situ on sun-damaged skin to noninvasive topical treatment was monitored using RCM. RCM is a promising and practical imaging tool for the diagnosis and follow-up of pigmented and nonpigmented skin lesions. 

*For a PDF of the full article, click on the link to the left of this introduction.

Reflectance confocal microscopy (RCM) allows noninvasive imaging of the epidermis and superficial dermis. Like dermoscopy, RCM acquires images in the horizontal plane (en face), allowing assessment of tissue pathology underlying dermoscopic structures of interest at a cellular-level resolution. Thus, clinicians using dermoscopy may find RCM to be particularly useful. Our aim was to show the value of RCM for diagnosis and management decisions related to pigmented and nonpigmented skin neoplasms seen in daily practice. Six cases of clinically and dermoscopically equivocal skin lesions, for which RCM facilitated making the correct diagnosis, are presented. Final diagnoses were made based on histopathologic analysis. Three flat pigmented skin lesions with dermoscopic signs of regression showed distinct RCM features that allowed their correct classification as pigmented basal cell carcinoma, pigmented actinic keratosis, and melanoma on sundamaged skin. A flat nonpigmented skin lesion on the face, which did not show distinct clinical or dermoscopic features, was correctly diagnosed as basal cell carcinoma based on RCM findings. In addition, the response of a pigmented actinic keratosis and a melanoma in situ on sun-damaged skin to noninvasive topical treatment was monitored using RCM. RCM is a promising and practical imaging tool for the diagnosis and follow-up of pigmented and nonpigmented skin lesions. 

*For a PDF of the full article, click on the link to the left of this introduction.

The increasing incidence of skin cancer and the importance of early diagnosis is a challenge, which requires the development of reliable, cost-effective, noninvasive, diagnostic techniques. Several such methods based on optical imaging techniques are available and currently being investigated. A novel method in this field is multiphoton laser scanning microscopy (MPLSM). This technique is based on the nonlinear process of 2-photon excitation of endogenous fluorophores, which can be used to acquire horizontal optical sectioning of intact biological tissue samples. When studying human skin, MPLSM provides high-resolution fluorescence imaging, allowing visualization of cellular and subcellular structures of the epidermis and upper dermis. This review covers the application of MPLSM as a diagnostic tool for superficial skin cancers, such as basal cell carcinomas, squamous cell carcinoma in situ, and melanomas. MPLSM has also been applied in other research areas related to skin, which will be mentioned briefly. The morphologic features observed in MPLSM images of skin tumors are comparable to traditional histopathology. Safety issues, limitations, and further improvements are discussed. Although further investigations are required to make MPLSM a mainstream clinical diagnostic tool, MPLSM has the potential of becoming a noninvasive, bedside, histopathologic technique for the diagnosis of superficial skin cancers.

*For a PDF of the full article, click on the link to the left of this introduction.

The increasing incidence of skin cancer and the importance of early diagnosis is a challenge, which requires the development of reliable, cost-effective, noninvasive, diagnostic techniques. Several such methods based on optical imaging techniques are available and currently being investigated. A novel method in this field is multiphoton laser scanning microscopy (MPLSM). This technique is based on the nonlinear process of 2-photon excitation of endogenous fluorophores, which can be used to acquire horizontal optical sectioning of intact biological tissue samples. When studying human skin, MPLSM provides high-resolution fluorescence imaging, allowing visualization of cellular and subcellular structures of the epidermis and upper dermis. This review covers the application of MPLSM as a diagnostic tool for superficial skin cancers, such as basal cell carcinomas, squamous cell carcinoma in situ, and melanomas. MPLSM has also been applied in other research areas related to skin, which will be mentioned briefly. The morphologic features observed in MPLSM images of skin tumors are comparable to traditional histopathology. Safety issues, limitations, and further improvements are discussed. Although further investigations are required to make MPLSM a mainstream clinical diagnostic tool, MPLSM has the potential of becoming a noninvasive, bedside, histopathologic technique for the diagnosis of superficial skin cancers.

*For a PDF of the full article, click on the link to the left of this introduction.

The increasing incidence of skin cancer and the importance of early diagnosis is a challenge, which requires the development of reliable, cost-effective, noninvasive, diagnostic techniques. Several such methods based on optical imaging techniques are available and currently being investigated. A novel method in this field is multiphoton laser scanning microscopy (MPLSM). This technique is based on the nonlinear process of 2-photon excitation of endogenous fluorophores, which can be used to acquire horizontal optical sectioning of intact biological tissue samples. When studying human skin, MPLSM provides high-resolution fluorescence imaging, allowing visualization of cellular and subcellular structures of the epidermis and upper dermis. This review covers the application of MPLSM as a diagnostic tool for superficial skin cancers, such as basal cell carcinomas, squamous cell carcinoma in situ, and melanomas. MPLSM has also been applied in other research areas related to skin, which will be mentioned briefly. The morphologic features observed in MPLSM images of skin tumors are comparable to traditional histopathology. Safety issues, limitations, and further improvements are discussed. Although further investigations are required to make MPLSM a mainstream clinical diagnostic tool, MPLSM has the potential of becoming a noninvasive, bedside, histopathologic technique for the diagnosis of superficial skin cancers.

*For a PDF of the full article, click on the link to the left of this introduction.

Optical coherence tomography (OCT) is an emerging imaging technology based on light reflection. It provides real-time images with up to 2-mm penetration into the skin and a resolution of approximately 10 m. It is routinely used in ophthalmology. The normal skin and its appendages have been studied, as have many diseases. The method can provide accurate measures of epidermal and nail changes in normal tissue. Skin cancer and other tumors, as well as inflammatory diseases, have been studied and good agreement found between OCT images and histopathological architecture. OCT also allows noninvasive monitoring of morphologic changes in skin diseases and may have a particular role in the monitoring of medical treatment of nonmelanoma skin cancer. The technology is however still evolving and continued technological development will necessitate an ongoing evaluation of its diagnostic accuracy. Several technical solutions are being pursued to further improve the quality of the images and the data provided, and OCT is being integrated in multimodal imaging devices that would potentially be able to provide a quantum leap to the imaging of skin in vivo.

*For a PDF of the full article, click on the link to the left of this introduction.

Optical coherence tomography (OCT) is an emerging imaging technology based on light reflection. It provides real-time images with up to 2-mm penetration into the skin and a resolution of approximately 10 m. It is routinely used in ophthalmology. The normal skin and its appendages have been studied, as have many diseases. The method can provide accurate measures of epidermal and nail changes in normal tissue. Skin cancer and other tumors, as well as inflammatory diseases, have been studied and good agreement found between OCT images and histopathological architecture. OCT also allows noninvasive monitoring of morphologic changes in skin diseases and may have a particular role in the monitoring of medical treatment of nonmelanoma skin cancer. The technology is however still evolving and continued technological development will necessitate an ongoing evaluation of its diagnostic accuracy. Several technical solutions are being pursued to further improve the quality of the images and the data provided, and OCT is being integrated in multimodal imaging devices that would potentially be able to provide a quantum leap to the imaging of skin in vivo.

*For a PDF of the full article, click on the link to the left of this introduction.

Optical coherence tomography (OCT) is an emerging imaging technology based on light reflection. It provides real-time images with up to 2-mm penetration into the skin and a resolution of approximately 10 m. It is routinely used in ophthalmology. The normal skin and its appendages have been studied, as have many diseases. The method can provide accurate measures of epidermal and nail changes in normal tissue. Skin cancer and other tumors, as well as inflammatory diseases, have been studied and good agreement found between OCT images and histopathological architecture. OCT also allows noninvasive monitoring of morphologic changes in skin diseases and may have a particular role in the monitoring of medical treatment of nonmelanoma skin cancer. The technology is however still evolving and continued technological development will necessitate an ongoing evaluation of its diagnostic accuracy. Several technical solutions are being pursued to further improve the quality of the images and the data provided, and OCT is being integrated in multimodal imaging devices that would potentially be able to provide a quantum leap to the imaging of skin in vivo.

*For a PDF of the full article, click on the link to the left of this introduction.

Mobile telemedicine integrates wireless communications for different telemedical applications, such as mobile phones and personal digital assistants, and with the implementation of modern wireless telecommunication, wireless local area network and satellite communication is a reality. New generation cellular phones or personal digital assistants have overcome limitations of image quality seen in older devices and, with dermatology being a visual profession, mobile teledermatology is perhaps the most recent development in this field. Mobile teledermatology may provide a triage service aimed toward management of patients with emergent skin disease or for follow-up with patients requiring systemic treatment. Teledermoscopy enables rapid transmission of dermoscopic images via e-mail or specific web-application and studies have demonstrated a high, 91%, concordance between face-to-face diagnosis and remote diagnosis of such images. Further to this, telediagnosis of melanocytic skin neoplasms achieved a diagnostic accuracy of 83% versus the conventional histopathologic diagnosis. Mobile teledermoscopy is the combination of such approaches enabling transfer of images captured with cellular phones coupled with a pocket dermatoscope and preliminary studies have demonstrated the feasibility and potential of its use in triage of pigmented lesions. Such applications are of benefit to physicians in enabling easy storage of data for follow-up or referral of images for expert second opinion and may facilitate a “person-centered health system” for patients with numerous moles and pigmented skin lesions who could forward images for evaluation. The incidence of skin cancers has reached epidemic proportions among whites and the trend is still going upward. Mobile teledermatology and teledermoscopy may be implemented as a triage or screening tool for malignant tumors to facilitate early detection and diagnosis, which is crucial for improved patient outcomes. While the legal aspects concerning teleconsultations need to be evaluated, the communications technologies provide a unique opportunity for physicians and patients alike and we foresee a place for these tools in dermatology soon.

*For a PDF of the full article, click on the link to the left of this introduction.

Mobile telemedicine integrates wireless communications for different telemedical applications, such as mobile phones and personal digital assistants, and with the implementation of modern wireless telecommunication, wireless local area network and satellite communication is a reality. New generation cellular phones or personal digital assistants have overcome limitations of image quality seen in older devices and, with dermatology being a visual profession, mobile teledermatology is perhaps the most recent development in this field. Mobile teledermatology may provide a triage service aimed toward management of patients with emergent skin disease or for follow-up with patients requiring systemic treatment. Teledermoscopy enables rapid transmission of dermoscopic images via e-mail or specific web-application and studies have demonstrated a high, 91%, concordance between face-to-face diagnosis and remote diagnosis of such images. Further to this, telediagnosis of melanocytic skin neoplasms achieved a diagnostic accuracy of 83% versus the conventional histopathologic diagnosis. Mobile teledermoscopy is the combination of such approaches enabling transfer of images captured with cellular phones coupled with a pocket dermatoscope and preliminary studies have demonstrated the feasibility and potential of its use in triage of pigmented lesions. Such applications are of benefit to physicians in enabling easy storage of data for follow-up or referral of images for expert second opinion and may facilitate a “person-centered health system” for patients with numerous moles and pigmented skin lesions who could forward images for evaluation. The incidence of skin cancers has reached epidemic proportions among whites and the trend is still going upward. Mobile teledermatology and teledermoscopy may be implemented as a triage or screening tool for malignant tumors to facilitate early detection and diagnosis, which is crucial for improved patient outcomes. While the legal aspects concerning teleconsultations need to be evaluated, the communications technologies provide a unique opportunity for physicians and patients alike and we foresee a place for these tools in dermatology soon.

*For a PDF of the full article, click on the link to the left of this introduction.

Mobile telemedicine integrates wireless communications for different telemedical applications, such as mobile phones and personal digital assistants, and with the implementation of modern wireless telecommunication, wireless local area network and satellite communication is a reality. New generation cellular phones or personal digital assistants have overcome limitations of image quality seen in older devices and, with dermatology being a visual profession, mobile teledermatology is perhaps the most recent development in this field. Mobile teledermatology may provide a triage service aimed toward management of patients with emergent skin disease or for follow-up with patients requiring systemic treatment. Teledermoscopy enables rapid transmission of dermoscopic images via e-mail or specific web-application and studies have demonstrated a high, 91%, concordance between face-to-face diagnosis and remote diagnosis of such images. Further to this, telediagnosis of melanocytic skin neoplasms achieved a diagnostic accuracy of 83% versus the conventional histopathologic diagnosis. Mobile teledermoscopy is the combination of such approaches enabling transfer of images captured with cellular phones coupled with a pocket dermatoscope and preliminary studies have demonstrated the feasibility and potential of its use in triage of pigmented lesions. Such applications are of benefit to physicians in enabling easy storage of data for follow-up or referral of images for expert second opinion and may facilitate a “person-centered health system” for patients with numerous moles and pigmented skin lesions who could forward images for evaluation. The incidence of skin cancers has reached epidemic proportions among whites and the trend is still going upward. Mobile teledermatology and teledermoscopy may be implemented as a triage or screening tool for malignant tumors to facilitate early detection and diagnosis, which is crucial for improved patient outcomes. While the legal aspects concerning teleconsultations need to be evaluated, the communications technologies provide a unique opportunity for physicians and patients alike and we foresee a place for these tools in dermatology soon.

*For a PDF of the full article, click on the link to the left of this introduction.

Antioxidant supplements do not appear to increase the risk of melanoma, according to a large, population-based study.

None of the exposure variables examined—overall antioxidant use, duration of use over the past 10 years, total dosage expressed in pill-years, or years of adult use during adulthood—correlated with melanoma risk in either men or women, said Dr. Maryam M. Asgari of Kaiser Permanente Northern California, Oakland, and her associates.

They undertook this study because the Supplementation in Vitamins and Mineral Antioxidants (SUVIMAX) study, a primary prevention trial published in 2007, found that daily oral supplementation with a combination of antioxidants raised the incidence of melanoma in women. The SUVIMAX findings were alarming, given that an estimated 48%–55% of American adults use supplements regularly, Dr. Asgari and her colleagues wrote.

They further examined the issue in a cohort of 69,671 adults who answered a 24-page questionnaire regarding health history, lifestyle factors, diet, supplement use, and cancer risk factors. They focused on the five antioxidants assessed in the SUVIMAX trial: vitamin C, vitamin E, zinc, beta carotene, and selenium.

Most of the study subjects (66%) were either current or former users of multivitamins. During 7 years of follow-up there were 461 incident cases of cutaneous melanoma.

Antioxidants were not associated with the disease. “Specifically, in the highest dose category of multivitamins … there was no increased risk of melanoma. Results were similar in men and women,” the investigators wrote (Arch. Dermatol. 2009;145:879–82).

Moreover, since many people take multivitamins plus additional beta carotene and selenium supplements, comparably high doses of these two nutrients were tested in a separate analysis. Again, no increased risk of melanoma was found and the results were the same for women and men.

It is likely that the SUVIMAX findings “could be explained by methodological shortcomings,” Dr. Asgari and her associates wrote.

In that study, subjects answered only a single question pertaining to their lifetime sun exposure, and “the analysis was based on only 16 cases” of melanoma. In addition, the incidence of melanoma in the SUVIMAX population was only 25 cases per 100,000 person-years—one-fifth the rate in the current study.

The work of Dr. Asgari and her associates was supported in part by the National Institute of Arthritis, Musculoskeletal and Skin Diseases and the National Cancer Institute. No financial conflicts of interest were reported.

Antioxidant supplements do not appear to increase the risk of melanoma, according to a large, population-based study.

None of the exposure variables examined—overall antioxidant use, duration of use over the past 10 years, total dosage expressed in pill-years, or years of adult use during adulthood—correlated with melanoma risk in either men or women, said Dr. Maryam M. Asgari of Kaiser Permanente Northern California, Oakland, and her associates.

They undertook this study because the Supplementation in Vitamins and Mineral Antioxidants (SUVIMAX) study, a primary prevention trial published in 2007, found that daily oral supplementation with a combination of antioxidants raised the incidence of melanoma in women. The SUVIMAX findings were alarming, given that an estimated 48%–55% of American adults use supplements regularly, Dr. Asgari and her colleagues wrote.

They further examined the issue in a cohort of 69,671 adults who answered a 24-page questionnaire regarding health history, lifestyle factors, diet, supplement use, and cancer risk factors. They focused on the five antioxidants assessed in the SUVIMAX trial: vitamin C, vitamin E, zinc, beta carotene, and selenium.

Most of the study subjects (66%) were either current or former users of multivitamins. During 7 years of follow-up there were 461 incident cases of cutaneous melanoma.

Antioxidants were not associated with the disease. “Specifically, in the highest dose category of multivitamins … there was no increased risk of melanoma. Results were similar in men and women,” the investigators wrote (Arch. Dermatol. 2009;145:879–82).

Moreover, since many people take multivitamins plus additional beta carotene and selenium supplements, comparably high doses of these two nutrients were tested in a separate analysis. Again, no increased risk of melanoma was found and the results were the same for women and men.

It is likely that the SUVIMAX findings “could be explained by methodological shortcomings,” Dr. Asgari and her associates wrote.

In that study, subjects answered only a single question pertaining to their lifetime sun exposure, and “the analysis was based on only 16 cases” of melanoma. In addition, the incidence of melanoma in the SUVIMAX population was only 25 cases per 100,000 person-years—one-fifth the rate in the current study.

The work of Dr. Asgari and her associates was supported in part by the National Institute of Arthritis, Musculoskeletal and Skin Diseases and the National Cancer Institute. No financial conflicts of interest were reported.

Antioxidant supplements do not appear to increase the risk of melanoma, according to a large, population-based study.

None of the exposure variables examined—overall antioxidant use, duration of use over the past 10 years, total dosage expressed in pill-years, or years of adult use during adulthood—correlated with melanoma risk in either men or women, said Dr. Maryam M. Asgari of Kaiser Permanente Northern California, Oakland, and her associates.

They undertook this study because the Supplementation in Vitamins and Mineral Antioxidants (SUVIMAX) study, a primary prevention trial published in 2007, found that daily oral supplementation with a combination of antioxidants raised the incidence of melanoma in women. The SUVIMAX findings were alarming, given that an estimated 48%–55% of American adults use supplements regularly, Dr. Asgari and her colleagues wrote.

They further examined the issue in a cohort of 69,671 adults who answered a 24-page questionnaire regarding health history, lifestyle factors, diet, supplement use, and cancer risk factors. They focused on the five antioxidants assessed in the SUVIMAX trial: vitamin C, vitamin E, zinc, beta carotene, and selenium.

Most of the study subjects (66%) were either current or former users of multivitamins. During 7 years of follow-up there were 461 incident cases of cutaneous melanoma.

Antioxidants were not associated with the disease. “Specifically, in the highest dose category of multivitamins … there was no increased risk of melanoma. Results were similar in men and women,” the investigators wrote (Arch. Dermatol. 2009;145:879–82).

Moreover, since many people take multivitamins plus additional beta carotene and selenium supplements, comparably high doses of these two nutrients were tested in a separate analysis. Again, no increased risk of melanoma was found and the results were the same for women and men.

It is likely that the SUVIMAX findings “could be explained by methodological shortcomings,” Dr. Asgari and her associates wrote.

In that study, subjects answered only a single question pertaining to their lifetime sun exposure, and “the analysis was based on only 16 cases” of melanoma. In addition, the incidence of melanoma in the SUVIMAX population was only 25 cases per 100,000 person-years—one-fifth the rate in the current study.

The work of Dr. Asgari and her associates was supported in part by the National Institute of Arthritis, Musculoskeletal and Skin Diseases and the National Cancer Institute. No financial conflicts of interest were reported.

In patients attending a general dermatology practice, most melanomas diagnosed during a 3-year period were not the presenting complaint, but were only discovered because a dermatologist performed a full-body skin examination, according to a recent report.

Such melanomas, discovered incidentally during an unrelated office visit, were more likely to be thinner or in-situ lesions than those that were inquired about by the patient or someone who observed them on the patient, said Dr. Jonathan Kantor and Deborah E. Kantor, C.R.N.P., of North Florida Dermatology Associates, Jacksonville.

The U.S. Preventive Services Task Force has stated that current evidence is insufficient to recommend either for or against routine full-body melanoma screening, and previous studies of patients in tertiary referral centers have reported that physicians detect only 14%–34% of melanomas.

“Our aim was to determine the proportion of patients in a private dermatology practice in whom melanoma was detected but was not the presenting complaint. If a substantial proportion of melanomas are detected only after a dermatologist's examination, this may suggest that FBSE [full-body skin examination], and not simply a problem-focused approach, should at least be considered for selected patients,” the researchers said (Arch. Dermatol. 2009;145:873–6).

The findings also “may help to promote education and encourage future patients to avail themselves of full-body skin examination,” they added.

The investigators performed a retrospective case series of all patients diagnosed as having melanoma (51 cases) or melanoma in situ (75 cases) during a 3-year period. Patients were aged 15–92 years (mean age, 60 years).

A total of 56% of melanomas were discovered by a dermatologist and had not been noted by the patient, a spouse, a friend, or another physician. Similarly, 60% of the melanomas in situ were discovered by a dermatologist, they said.

“Moreover, we found that dermatologist detection was associated with thinner melanomas and an increasing likelihood of the melanoma being in-situ,” they said.

“Thus, full-body skin examinations confer both an absolute benefit (detecting most melanomas) as well as a clinically significant marginal benefit (detecting melanomas with less tumor thickness). We hope that these findings will help spur large population-based studies in high-risk populations to develop an evidence-based approach to determining appropriate screening practices and intervals,” the investigators added.

The researchers reported no financial disclosures.

In patients attending a general dermatology practice, most melanomas diagnosed during a 3-year period were not the presenting complaint, but were only discovered because a dermatologist performed a full-body skin examination, according to a recent report.

Such melanomas, discovered incidentally during an unrelated office visit, were more likely to be thinner or in-situ lesions than those that were inquired about by the patient or someone who observed them on the patient, said Dr. Jonathan Kantor and Deborah E. Kantor, C.R.N.P., of North Florida Dermatology Associates, Jacksonville.

The U.S. Preventive Services Task Force has stated that current evidence is insufficient to recommend either for or against routine full-body melanoma screening, and previous studies of patients in tertiary referral centers have reported that physicians detect only 14%–34% of melanomas.

“Our aim was to determine the proportion of patients in a private dermatology practice in whom melanoma was detected but was not the presenting complaint. If a substantial proportion of melanomas are detected only after a dermatologist's examination, this may suggest that FBSE [full-body skin examination], and not simply a problem-focused approach, should at least be considered for selected patients,” the researchers said (Arch. Dermatol. 2009;145:873–6).

The findings also “may help to promote education and encourage future patients to avail themselves of full-body skin examination,” they added.

The investigators performed a retrospective case series of all patients diagnosed as having melanoma (51 cases) or melanoma in situ (75 cases) during a 3-year period. Patients were aged 15–92 years (mean age, 60 years).

A total of 56% of melanomas were discovered by a dermatologist and had not been noted by the patient, a spouse, a friend, or another physician. Similarly, 60% of the melanomas in situ were discovered by a dermatologist, they said.

“Moreover, we found that dermatologist detection was associated with thinner melanomas and an increasing likelihood of the melanoma being in-situ,” they said.

“Thus, full-body skin examinations confer both an absolute benefit (detecting most melanomas) as well as a clinically significant marginal benefit (detecting melanomas with less tumor thickness). We hope that these findings will help spur large population-based studies in high-risk populations to develop an evidence-based approach to determining appropriate screening practices and intervals,” the investigators added.

The researchers reported no financial disclosures.

In patients attending a general dermatology practice, most melanomas diagnosed during a 3-year period were not the presenting complaint, but were only discovered because a dermatologist performed a full-body skin examination, according to a recent report.

Such melanomas, discovered incidentally during an unrelated office visit, were more likely to be thinner or in-situ lesions than those that were inquired about by the patient or someone who observed them on the patient, said Dr. Jonathan Kantor and Deborah E. Kantor, C.R.N.P., of North Florida Dermatology Associates, Jacksonville.

The U.S. Preventive Services Task Force has stated that current evidence is insufficient to recommend either for or against routine full-body melanoma screening, and previous studies of patients in tertiary referral centers have reported that physicians detect only 14%–34% of melanomas.

“Our aim was to determine the proportion of patients in a private dermatology practice in whom melanoma was detected but was not the presenting complaint. If a substantial proportion of melanomas are detected only after a dermatologist's examination, this may suggest that FBSE [full-body skin examination], and not simply a problem-focused approach, should at least be considered for selected patients,” the researchers said (Arch. Dermatol. 2009;145:873–6).

The findings also “may help to promote education and encourage future patients to avail themselves of full-body skin examination,” they added.

The investigators performed a retrospective case series of all patients diagnosed as having melanoma (51 cases) or melanoma in situ (75 cases) during a 3-year period. Patients were aged 15–92 years (mean age, 60 years).

A total of 56% of melanomas were discovered by a dermatologist and had not been noted by the patient, a spouse, a friend, or another physician. Similarly, 60% of the melanomas in situ were discovered by a dermatologist, they said.

“Moreover, we found that dermatologist detection was associated with thinner melanomas and an increasing likelihood of the melanoma being in-situ,” they said.

“Thus, full-body skin examinations confer both an absolute benefit (detecting most melanomas) as well as a clinically significant marginal benefit (detecting melanomas with less tumor thickness). We hope that these findings will help spur large population-based studies in high-risk populations to develop an evidence-based approach to determining appropriate screening practices and intervals,” the investigators added.

The researchers reported no financial disclosures.

LONDON — International health officials declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer raised the ultraviolet ray-emitting tanning devices to their Group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices. "Therefore, the working group raised the classification of the use of UV-emitting tanning devices to Group 1, carcinogenic to humans," the report noted (Lancet Oncol. 2009;10:751–2).

"The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category," Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

"Given the dangers of sunbeds, we want the government to act now to ban under 18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers," she noted.

Based on animal studies, exposure to ultraviolet radiation was also added to the Group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors.

The working group also reaffirmed as Group 1 carcinogenic agents internally deposited radionuclides that emit alpha or beta particles, such as radon. Humans can be exposed to radon through soil and building materials. Also in Group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

The carcinogenic classification probably will not be enough to convince hard-core tanners to abandon their bronzing, said Mark Leary, Ph.D., director of the social psychology program at Duke University in Durham, N.C.

"I suspect that some people will rethink the importance of a tan with the new labeling, but I don't expect it to make a great difference," Dr. Leary said. "The perceived value of being tanned in terms of enhancing one's appearance and social acceptance is simply too strong."

Another reason that die-hard tanners probably won't quit—the short-term benefits of looking good carry more weight than the possibility of skin cancer 20–30 years down the road, Dr. Leary added.

He explained that tanning behaviors aren't likely to change unless the norms of attractiveness change so that paler skin becomes preferable. In the 1800s, for example, being tanned was a signal that you were a farmer or outdoor laborer, while pale skin signaled that you had an indoor, professional job, Dr. Leary said.

"Only after the Industrial Revolution moved much of the working class inside factories [where they developed pale skin] did being tanned signal status," he said.

The carcinogen message alone is unlikely to discourage teens and young adults from tanning, Dr. Leary added.

But Dr. Leary's previous research showed that an essay about the negative effects of tanning on appearance was more effective in reducing tanning than an essay about skin cancer. A publicity campaign featuring images of wrinkled, saggy skin in relatively young people might make an impact, he said.

LONDON — International health officials declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer raised the ultraviolet ray-emitting tanning devices to their Group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices. "Therefore, the working group raised the classification of the use of UV-emitting tanning devices to Group 1, carcinogenic to humans," the report noted (Lancet Oncol. 2009;10:751–2).

"The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category," Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

"Given the dangers of sunbeds, we want the government to act now to ban under 18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers," she noted.

Based on animal studies, exposure to ultraviolet radiation was also added to the Group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors.

The working group also reaffirmed as Group 1 carcinogenic agents internally deposited radionuclides that emit alpha or beta particles, such as radon. Humans can be exposed to radon through soil and building materials. Also in Group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

The carcinogenic classification probably will not be enough to convince hard-core tanners to abandon their bronzing, said Mark Leary, Ph.D., director of the social psychology program at Duke University in Durham, N.C.

"I suspect that some people will rethink the importance of a tan with the new labeling, but I don't expect it to make a great difference," Dr. Leary said. "The perceived value of being tanned in terms of enhancing one's appearance and social acceptance is simply too strong."

Another reason that die-hard tanners probably won't quit—the short-term benefits of looking good carry more weight than the possibility of skin cancer 20–30 years down the road, Dr. Leary added.

He explained that tanning behaviors aren't likely to change unless the norms of attractiveness change so that paler skin becomes preferable. In the 1800s, for example, being tanned was a signal that you were a farmer or outdoor laborer, while pale skin signaled that you had an indoor, professional job, Dr. Leary said.

"Only after the Industrial Revolution moved much of the working class inside factories [where they developed pale skin] did being tanned signal status," he said.

The carcinogen message alone is unlikely to discourage teens and young adults from tanning, Dr. Leary added.

But Dr. Leary's previous research showed that an essay about the negative effects of tanning on appearance was more effective in reducing tanning than an essay about skin cancer. A publicity campaign featuring images of wrinkled, saggy skin in relatively young people might make an impact, he said.

LONDON — International health officials declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer raised the ultraviolet ray-emitting tanning devices to their Group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices. "Therefore, the working group raised the classification of the use of UV-emitting tanning devices to Group 1, carcinogenic to humans," the report noted (Lancet Oncol. 2009;10:751–2).

"The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category," Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

"Given the dangers of sunbeds, we want the government to act now to ban under 18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers," she noted.

Based on animal studies, exposure to ultraviolet radiation was also added to the Group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors.

The working group also reaffirmed as Group 1 carcinogenic agents internally deposited radionuclides that emit alpha or beta particles, such as radon. Humans can be exposed to radon through soil and building materials. Also in Group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

The carcinogenic classification probably will not be enough to convince hard-core tanners to abandon their bronzing, said Mark Leary, Ph.D., director of the social psychology program at Duke University in Durham, N.C.

"I suspect that some people will rethink the importance of a tan with the new labeling, but I don't expect it to make a great difference," Dr. Leary said. "The perceived value of being tanned in terms of enhancing one's appearance and social acceptance is simply too strong."

Another reason that die-hard tanners probably won't quit—the short-term benefits of looking good carry more weight than the possibility of skin cancer 20–30 years down the road, Dr. Leary added.

He explained that tanning behaviors aren't likely to change unless the norms of attractiveness change so that paler skin becomes preferable. In the 1800s, for example, being tanned was a signal that you were a farmer or outdoor laborer, while pale skin signaled that you had an indoor, professional job, Dr. Leary said.

"Only after the Industrial Revolution moved much of the working class inside factories [where they developed pale skin] did being tanned signal status," he said.

The carcinogen message alone is unlikely to discourage teens and young adults from tanning, Dr. Leary added.

But Dr. Leary's previous research showed that an essay about the negative effects of tanning on appearance was more effective in reducing tanning than an essay about skin cancer. A publicity campaign featuring images of wrinkled, saggy skin in relatively young people might make an impact, he said.

Prophylactic budesonide did not significantly decrease the risk of grade 2 or higher diarrhea that is common in patients who have unresectable melanoma treated with the investigational drug ipilimumab, a phase II trial found.

Ipilimumab is a human monoclonal antibody directed against CTL antigen-4, which is a key negative regulator of the T-cell immune response. In clinical studies, immune-related adverse events associated with ipilimumab most commonly have involved the gastrointestinal tract or the skin.

Dr. Jeffrey Weber and his associates hypothesized that oral budesonide, which is used to treat grade 2 diarrhea when it accompanies ipilimumab therapy, might work as prophylaxis to prevent diarrhea without affecting any antitumor activity from ipilimumab.

They randomized 115 patients with unresectable stage III or IV melanoma to treatment with open-label IV ipilimumab (10 mg/kg every 3 weeks for four doses), plus blinded oral budesonide or placebo. The once-daily budesonide dose was 9 mg through week 12, then tapered until discontinuation at week 16.

Grade 2 or higher diarrhea occurred in 19 (33%) of the 58 patients in the budesonide group and 20 (35%) of the 57 patients in the placebo group, Dr. Weber and colleagues reported in an online article to appear in the Sept. 1, 2009, issue of Clinical Cancer Research (doi:10.1158/1078-0432.CCR-09-1024

Budesonide should not be used prophylactically for grade 2 or higher diarrhea associated with ipilimumab therapy, concluded Dr. Weber of the Moffitt Cancer Center and Research Institute, Tampa. Prompt treatment of diarrhea or colitis, however, seemed to be effective in preventing serious complications such as gastrointestinal perforations, he added.

Patients who developed grade 2 or higher diarrhea or other immune-related adverse events discontinued the blinded drug and started open-label therapy with budesonide or other steroids. If the diarrhea lasted 2 weeks or there was grade 3 or 4 diarrhea, they stopped ipilimumab. None of the patients developed gastrointestinal or colonic perforations.

Bristol-Myers Squibb, which is developing ipilimumab with Medarex, sponsored the study and funded editorial and writing assistance for the investigators. Dr. Weber and three of his associates have received funds for speaking, advising, and research for Bristol-Myers Squibb. Dr. Weber owns part of a patent with Medarex on CT2A-4 antibodies. The journal marked the article as an advertisement because page charges were levied to defray the costs of publication.

Grade 3–4 immune-related adverse events occurred in 46 (40%) of all patients, compared with rates of 25% and 22% in other studies that used the same dosing regimens of ipilimumab, the investigators noted. Unlike some of the earlier studies, the current trial included many patients with poor prognostic markers.

Immune-related adverse events affecting the skin, gastrointestinal system, liver, endocrine system, or other area were seen in 47 patients (81%) in the budesonide group and 48 patients (84%) in the placebo group.

Secondary end points in the study included multiple measures of the efficacy of ipilimumab in treating melanoma. A complete response or partial response was seen in seven patients (12%) in the budesonide group and in nine patients (16%) in the placebo group. In addition, the disease stabilized in 11 patients (19%) in each group.

With a median follow-up of over 12 months, the median overall survival rate was 18 months in the budesonide group and 19 months on placebo.

Prophylactic budesonide did not significantly decrease the risk of grade 2 or higher diarrhea that is common in patients who have unresectable melanoma treated with the investigational drug ipilimumab, a phase II trial found.

Ipilimumab is a human monoclonal antibody directed against CTL antigen-4, which is a key negative regulator of the T-cell immune response. In clinical studies, immune-related adverse events associated with ipilimumab most commonly have involved the gastrointestinal tract or the skin.

Dr. Jeffrey Weber and his associates hypothesized that oral budesonide, which is used to treat grade 2 diarrhea when it accompanies ipilimumab therapy, might work as prophylaxis to prevent diarrhea without affecting any antitumor activity from ipilimumab.

They randomized 115 patients with unresectable stage III or IV melanoma to treatment with open-label IV ipilimumab (10 mg/kg every 3 weeks for four doses), plus blinded oral budesonide or placebo. The once-daily budesonide dose was 9 mg through week 12, then tapered until discontinuation at week 16.

Grade 2 or higher diarrhea occurred in 19 (33%) of the 58 patients in the budesonide group and 20 (35%) of the 57 patients in the placebo group, Dr. Weber and colleagues reported in an online article to appear in the Sept. 1, 2009, issue of Clinical Cancer Research (doi:10.1158/1078-0432.CCR-09-1024

Budesonide should not be used prophylactically for grade 2 or higher diarrhea associated with ipilimumab therapy, concluded Dr. Weber of the Moffitt Cancer Center and Research Institute, Tampa. Prompt treatment of diarrhea or colitis, however, seemed to be effective in preventing serious complications such as gastrointestinal perforations, he added.

Patients who developed grade 2 or higher diarrhea or other immune-related adverse events discontinued the blinded drug and started open-label therapy with budesonide or other steroids. If the diarrhea lasted 2 weeks or there was grade 3 or 4 diarrhea, they stopped ipilimumab. None of the patients developed gastrointestinal or colonic perforations.

Bristol-Myers Squibb, which is developing ipilimumab with Medarex, sponsored the study and funded editorial and writing assistance for the investigators. Dr. Weber and three of his associates have received funds for speaking, advising, and research for Bristol-Myers Squibb. Dr. Weber owns part of a patent with Medarex on CT2A-4 antibodies. The journal marked the article as an advertisement because page charges were levied to defray the costs of publication.

Grade 3–4 immune-related adverse events occurred in 46 (40%) of all patients, compared with rates of 25% and 22% in other studies that used the same dosing regimens of ipilimumab, the investigators noted. Unlike some of the earlier studies, the current trial included many patients with poor prognostic markers.

Immune-related adverse events affecting the skin, gastrointestinal system, liver, endocrine system, or other area were seen in 47 patients (81%) in the budesonide group and 48 patients (84%) in the placebo group.

Secondary end points in the study included multiple measures of the efficacy of ipilimumab in treating melanoma. A complete response or partial response was seen in seven patients (12%) in the budesonide group and in nine patients (16%) in the placebo group. In addition, the disease stabilized in 11 patients (19%) in each group.

With a median follow-up of over 12 months, the median overall survival rate was 18 months in the budesonide group and 19 months on placebo.

Prophylactic budesonide did not significantly decrease the risk of grade 2 or higher diarrhea that is common in patients who have unresectable melanoma treated with the investigational drug ipilimumab, a phase II trial found.

Ipilimumab is a human monoclonal antibody directed against CTL antigen-4, which is a key negative regulator of the T-cell immune response. In clinical studies, immune-related adverse events associated with ipilimumab most commonly have involved the gastrointestinal tract or the skin.

Dr. Jeffrey Weber and his associates hypothesized that oral budesonide, which is used to treat grade 2 diarrhea when it accompanies ipilimumab therapy, might work as prophylaxis to prevent diarrhea without affecting any antitumor activity from ipilimumab.

They randomized 115 patients with unresectable stage III or IV melanoma to treatment with open-label IV ipilimumab (10 mg/kg every 3 weeks for four doses), plus blinded oral budesonide or placebo. The once-daily budesonide dose was 9 mg through week 12, then tapered until discontinuation at week 16.

Grade 2 or higher diarrhea occurred in 19 (33%) of the 58 patients in the budesonide group and 20 (35%) of the 57 patients in the placebo group, Dr. Weber and colleagues reported in an online article to appear in the Sept. 1, 2009, issue of Clinical Cancer Research (doi:10.1158/1078-0432.CCR-09-1024

Budesonide should not be used prophylactically for grade 2 or higher diarrhea associated with ipilimumab therapy, concluded Dr. Weber of the Moffitt Cancer Center and Research Institute, Tampa. Prompt treatment of diarrhea or colitis, however, seemed to be effective in preventing serious complications such as gastrointestinal perforations, he added.

Patients who developed grade 2 or higher diarrhea or other immune-related adverse events discontinued the blinded drug and started open-label therapy with budesonide or other steroids. If the diarrhea lasted 2 weeks or there was grade 3 or 4 diarrhea, they stopped ipilimumab. None of the patients developed gastrointestinal or colonic perforations.

Bristol-Myers Squibb, which is developing ipilimumab with Medarex, sponsored the study and funded editorial and writing assistance for the investigators. Dr. Weber and three of his associates have received funds for speaking, advising, and research for Bristol-Myers Squibb. Dr. Weber owns part of a patent with Medarex on CT2A-4 antibodies. The journal marked the article as an advertisement because page charges were levied to defray the costs of publication.

Grade 3–4 immune-related adverse events occurred in 46 (40%) of all patients, compared with rates of 25% and 22% in other studies that used the same dosing regimens of ipilimumab, the investigators noted. Unlike some of the earlier studies, the current trial included many patients with poor prognostic markers.

Immune-related adverse events affecting the skin, gastrointestinal system, liver, endocrine system, or other area were seen in 47 patients (81%) in the budesonide group and 48 patients (84%) in the placebo group.

Secondary end points in the study included multiple measures of the efficacy of ipilimumab in treating melanoma. A complete response or partial response was seen in seven patients (12%) in the budesonide group and in nine patients (16%) in the placebo group. In addition, the disease stabilized in 11 patients (19%) in each group.

With a median follow-up of over 12 months, the median overall survival rate was 18 months in the budesonide group and 19 months on placebo.