Melanoma

TORONTO — Ulceration and depth of invasion should be included in the staging of Merkel cell cancers, as they are for the staging of melanoma, because of the strong similarities between the two types of neoplasm, Dr. Ralph L. George and Dr. A. McGuire said in a poster presented at the annual meeting of the Canadian Association of Thoracic Surgeons.

As with melanoma, ulceration in a primary Merkel cell cancer appears to be an indication that the tumor has spread.

An analysis of 14 Merkel cell cancer cases found that ulceration was significantly associated with metastatic disease. Depth of invasion was also a sign of advanced disease that "approached but did not achieve statistical significance," Dr. George said in an interview.

Merkel cell cancer is a rare form of cutaneous neuroendocrine neoplasm that is known to have a poor prognosis, but there is limited information on staging Merkel cell cancer and no data on the prognostic significance of ulceration, wrote Dr. George and Dr. McGuire of Kingston (Ont.) Regional Cancer Centre, Queen's University.

After noticing that patients coming to their clinic with either of the cancers had the same risk factors, the physicians decided to compare the prognostic and etiologic characteristics of 232 melanoma cases with those of the Merkel cases.

They documented several important similarities. Like melanoma, Merkel cell cancer was most common in type I, II, and III skin and on sun-exposed areas of the body. In fact, Merkel cell cancer's relationship with sun exposure was "even stronger than that of the melanomas, with a P value equal to .026 for the comparison," Dr. George said.

Like melanoma, Merkel cell cancer occurred more in older patients and showed a propensity for full-thickness skin invasion, metastases to regional lymph nodes, and systemic failure.

These data are preliminary and need to be confirmed in a larger study. "Knowing about the staging [may] lead to better treatment. We have systemic treatment for melanoma but we do not have … an effective systemic treatment for Merkel at this time. If we can predict a group who are likely to fail, we can perhaps target them with adjuvant therapy," Dr. George said.

TORONTO — Ulceration and depth of invasion should be included in the staging of Merkel cell cancers, as they are for the staging of melanoma, because of the strong similarities between the two types of neoplasm, Dr. Ralph L. George and Dr. A. McGuire said in a poster presented at the annual meeting of the Canadian Association of Thoracic Surgeons.

As with melanoma, ulceration in a primary Merkel cell cancer appears to be an indication that the tumor has spread.

An analysis of 14 Merkel cell cancer cases found that ulceration was significantly associated with metastatic disease. Depth of invasion was also a sign of advanced disease that "approached but did not achieve statistical significance," Dr. George said in an interview.

Merkel cell cancer is a rare form of cutaneous neuroendocrine neoplasm that is known to have a poor prognosis, but there is limited information on staging Merkel cell cancer and no data on the prognostic significance of ulceration, wrote Dr. George and Dr. McGuire of Kingston (Ont.) Regional Cancer Centre, Queen's University.

After noticing that patients coming to their clinic with either of the cancers had the same risk factors, the physicians decided to compare the prognostic and etiologic characteristics of 232 melanoma cases with those of the Merkel cases.

They documented several important similarities. Like melanoma, Merkel cell cancer was most common in type I, II, and III skin and on sun-exposed areas of the body. In fact, Merkel cell cancer's relationship with sun exposure was "even stronger than that of the melanomas, with a P value equal to .026 for the comparison," Dr. George said.

Like melanoma, Merkel cell cancer occurred more in older patients and showed a propensity for full-thickness skin invasion, metastases to regional lymph nodes, and systemic failure.

These data are preliminary and need to be confirmed in a larger study. "Knowing about the staging [may] lead to better treatment. We have systemic treatment for melanoma but we do not have … an effective systemic treatment for Merkel at this time. If we can predict a group who are likely to fail, we can perhaps target them with adjuvant therapy," Dr. George said.

TORONTO — Ulceration and depth of invasion should be included in the staging of Merkel cell cancers, as they are for the staging of melanoma, because of the strong similarities between the two types of neoplasm, Dr. Ralph L. George and Dr. A. McGuire said in a poster presented at the annual meeting of the Canadian Association of Thoracic Surgeons.

As with melanoma, ulceration in a primary Merkel cell cancer appears to be an indication that the tumor has spread.

An analysis of 14 Merkel cell cancer cases found that ulceration was significantly associated with metastatic disease. Depth of invasion was also a sign of advanced disease that "approached but did not achieve statistical significance," Dr. George said in an interview.

Merkel cell cancer is a rare form of cutaneous neuroendocrine neoplasm that is known to have a poor prognosis, but there is limited information on staging Merkel cell cancer and no data on the prognostic significance of ulceration, wrote Dr. George and Dr. McGuire of Kingston (Ont.) Regional Cancer Centre, Queen's University.

After noticing that patients coming to their clinic with either of the cancers had the same risk factors, the physicians decided to compare the prognostic and etiologic characteristics of 232 melanoma cases with those of the Merkel cases.

They documented several important similarities. Like melanoma, Merkel cell cancer was most common in type I, II, and III skin and on sun-exposed areas of the body. In fact, Merkel cell cancer's relationship with sun exposure was "even stronger than that of the melanomas, with a P value equal to .026 for the comparison," Dr. George said.

Like melanoma, Merkel cell cancer occurred more in older patients and showed a propensity for full-thickness skin invasion, metastases to regional lymph nodes, and systemic failure.

These data are preliminary and need to be confirmed in a larger study. "Knowing about the staging [may] lead to better treatment. We have systemic treatment for melanoma but we do not have … an effective systemic treatment for Merkel at this time. If we can predict a group who are likely to fail, we can perhaps target them with adjuvant therapy," Dr. George said.

CHICAGO — Dermatologists who conducted complete skin examinations of all their patients would detect more melanomas, and those cancers would be detected earlier, Dr. Jonathan Kantor said at the annual meeting of the American Society for Dermatologic Surgery.

"Full skin examination is a critical tool for detecting melanoma in patients visiting a dermatology or dermatologic surgery office," said Dr. Jonathan Kantor, who is in private practice in Jacksonville, Fla.

According to one published survey, only about 30% of dermatologists perform full skin examinations on all their patients, and half of respondents said that they screened only those patients deemed to be at increased risk (J. Am. Acad. Dermatol. 2002;46:710-4).

This survey "suggests that half of dermatologists are not screening patients at high risk of melanoma," said Dr. Kantor.

"Clearly, we cannot find all melanomas just by saying "hello," shaking the patient's hand, and talking to him about his acne. We know that when we screen patients actively, we're going to find melanomas at earlier stages," he said.

For this study, Dr. Kantor drew on 2 years of data on 76 consecutive patients who were diagnosed in an office setting, either with invasive melanoma (30) or melanoma in situ (46). Their average age was 60 years; 63% were men.

A total of 41 patients (54%) had made appointments because they saw something suspicious on their skin and thought it should be looked at. The remaining 35 (46%) came in for other reasons, such as acne, dry skin, warts, and other conditions, he explained.

Body locations for the melanomas were fairly evenly distributed among the head and neck, trunk, and extremities, with the lower extremities being slightly less represented. The trunk was the most common site of melanomas in men, but the legs were the most common site for women.

Dr. Kantor concluded that 46% of all the melanomas (43% of invasive melanomas and 48% of in situ lesions) may not have been found without the careful skin examination.

Physician-detected melanomas tended to be thinner, and at the in situ stage; although these trends were not statistically significant, they highlight the clinical validity of the study data. "It makes sense that screening finds melanoma earlier and at a stage where hopefully they're more likely to respond to treatment," Dr. Kantor said.

Although he believes that this study has implications for both clinical practice and health policy—including screening recommendations—he conceded its important limitations. "Obviously, these data are not generalizable and this was a retrospective analytical case series, which limits further analysis. Also, there's the issue of screening versus examination. Those who are examined in a physician's office may be at higher risk than those who attend skin cancer screenings," he said.

Yet, he added, dermatologists should consider doing complete skin examinations on all patients and let future studies fill in the gaps left by this initial research.

The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to recommend for or against routine screening for skin cancer using a total body examination.

"One of my main jobs as a dermatologist is to find melanoma and melanoma in situ, because early detection is an inconvenience while late detection becomes a tragedy," Dr. Kantor said, pointing out that the 10-year survival rate drops from 88% for a 1-mm melanoma to 32% for an ulcerated melanoma larger than 4 mm.

And melanoma in situ should never be underestimated, he added, explaining that in a study of 104 reassessed patients, almost a third of melanomas in situ were reclassified as invasive melanoma (Lancet 2002;359:1921-2).

This melanoma in situ was found on the foot of an 88-year-old who presented with a complaint of dry skin. Her toe was saved with geometric excision. Courtesy Dr. Jonathan Kantor

CHICAGO — Dermatologists who conducted complete skin examinations of all their patients would detect more melanomas, and those cancers would be detected earlier, Dr. Jonathan Kantor said at the annual meeting of the American Society for Dermatologic Surgery.

"Full skin examination is a critical tool for detecting melanoma in patients visiting a dermatology or dermatologic surgery office," said Dr. Jonathan Kantor, who is in private practice in Jacksonville, Fla.

According to one published survey, only about 30% of dermatologists perform full skin examinations on all their patients, and half of respondents said that they screened only those patients deemed to be at increased risk (J. Am. Acad. Dermatol. 2002;46:710-4).

This survey "suggests that half of dermatologists are not screening patients at high risk of melanoma," said Dr. Kantor.

"Clearly, we cannot find all melanomas just by saying "hello," shaking the patient's hand, and talking to him about his acne. We know that when we screen patients actively, we're going to find melanomas at earlier stages," he said.

For this study, Dr. Kantor drew on 2 years of data on 76 consecutive patients who were diagnosed in an office setting, either with invasive melanoma (30) or melanoma in situ (46). Their average age was 60 years; 63% were men.

A total of 41 patients (54%) had made appointments because they saw something suspicious on their skin and thought it should be looked at. The remaining 35 (46%) came in for other reasons, such as acne, dry skin, warts, and other conditions, he explained.

Body locations for the melanomas were fairly evenly distributed among the head and neck, trunk, and extremities, with the lower extremities being slightly less represented. The trunk was the most common site of melanomas in men, but the legs were the most common site for women.

Dr. Kantor concluded that 46% of all the melanomas (43% of invasive melanomas and 48% of in situ lesions) may not have been found without the careful skin examination.

Physician-detected melanomas tended to be thinner, and at the in situ stage; although these trends were not statistically significant, they highlight the clinical validity of the study data. "It makes sense that screening finds melanoma earlier and at a stage where hopefully they're more likely to respond to treatment," Dr. Kantor said.

Although he believes that this study has implications for both clinical practice and health policy—including screening recommendations—he conceded its important limitations. "Obviously, these data are not generalizable and this was a retrospective analytical case series, which limits further analysis. Also, there's the issue of screening versus examination. Those who are examined in a physician's office may be at higher risk than those who attend skin cancer screenings," he said.

Yet, he added, dermatologists should consider doing complete skin examinations on all patients and let future studies fill in the gaps left by this initial research.

The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to recommend for or against routine screening for skin cancer using a total body examination.

"One of my main jobs as a dermatologist is to find melanoma and melanoma in situ, because early detection is an inconvenience while late detection becomes a tragedy," Dr. Kantor said, pointing out that the 10-year survival rate drops from 88% for a 1-mm melanoma to 32% for an ulcerated melanoma larger than 4 mm.

And melanoma in situ should never be underestimated, he added, explaining that in a study of 104 reassessed patients, almost a third of melanomas in situ were reclassified as invasive melanoma (Lancet 2002;359:1921-2).

This melanoma in situ was found on the foot of an 88-year-old who presented with a complaint of dry skin. Her toe was saved with geometric excision. Courtesy Dr. Jonathan Kantor

CHICAGO — Dermatologists who conducted complete skin examinations of all their patients would detect more melanomas, and those cancers would be detected earlier, Dr. Jonathan Kantor said at the annual meeting of the American Society for Dermatologic Surgery.

"Full skin examination is a critical tool for detecting melanoma in patients visiting a dermatology or dermatologic surgery office," said Dr. Jonathan Kantor, who is in private practice in Jacksonville, Fla.

According to one published survey, only about 30% of dermatologists perform full skin examinations on all their patients, and half of respondents said that they screened only those patients deemed to be at increased risk (J. Am. Acad. Dermatol. 2002;46:710-4).

This survey "suggests that half of dermatologists are not screening patients at high risk of melanoma," said Dr. Kantor.

"Clearly, we cannot find all melanomas just by saying "hello," shaking the patient's hand, and talking to him about his acne. We know that when we screen patients actively, we're going to find melanomas at earlier stages," he said.

For this study, Dr. Kantor drew on 2 years of data on 76 consecutive patients who were diagnosed in an office setting, either with invasive melanoma (30) or melanoma in situ (46). Their average age was 60 years; 63% were men.

A total of 41 patients (54%) had made appointments because they saw something suspicious on their skin and thought it should be looked at. The remaining 35 (46%) came in for other reasons, such as acne, dry skin, warts, and other conditions, he explained.

Body locations for the melanomas were fairly evenly distributed among the head and neck, trunk, and extremities, with the lower extremities being slightly less represented. The trunk was the most common site of melanomas in men, but the legs were the most common site for women.

Dr. Kantor concluded that 46% of all the melanomas (43% of invasive melanomas and 48% of in situ lesions) may not have been found without the careful skin examination.

Physician-detected melanomas tended to be thinner, and at the in situ stage; although these trends were not statistically significant, they highlight the clinical validity of the study data. "It makes sense that screening finds melanoma earlier and at a stage where hopefully they're more likely to respond to treatment," Dr. Kantor said.

Although he believes that this study has implications for both clinical practice and health policy—including screening recommendations—he conceded its important limitations. "Obviously, these data are not generalizable and this was a retrospective analytical case series, which limits further analysis. Also, there's the issue of screening versus examination. Those who are examined in a physician's office may be at higher risk than those who attend skin cancer screenings," he said.

Yet, he added, dermatologists should consider doing complete skin examinations on all patients and let future studies fill in the gaps left by this initial research.

The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to recommend for or against routine screening for skin cancer using a total body examination.

"One of my main jobs as a dermatologist is to find melanoma and melanoma in situ, because early detection is an inconvenience while late detection becomes a tragedy," Dr. Kantor said, pointing out that the 10-year survival rate drops from 88% for a 1-mm melanoma to 32% for an ulcerated melanoma larger than 4 mm.

And melanoma in situ should never be underestimated, he added, explaining that in a study of 104 reassessed patients, almost a third of melanomas in situ were reclassified as invasive melanoma (Lancet 2002;359:1921-2).

This melanoma in situ was found on the foot of an 88-year-old who presented with a complaint of dry skin. Her toe was saved with geometric excision. Courtesy Dr. Jonathan Kantor

CHICAGO — Pulsed dye lasers may add a third option to the realm of treatments for superficial and nodular basal cell carcinomas less than 1.5 cm in diameter, according to Dr. Zeina Tannous, who performed a study of the treatment in 14 patients.

Unlike surgical excision or Mohs micrographic surgery, pulsed dye lasers selectively target vessels, said Dr. Tannous of Harvard Medical School, Boston, and chief of Mohs micrographic surgery at the Veterans Administration Hospital in Boston.

"Pulsed dye laser may allow for selective photothermolysis of pathological blood vessels and thus could be a nonsurgical treatment method for basal cell carcinomas, and this is important in patients with multiple tumors for whom surgery may be risky."

In her study, presented at the annual meeting of the American Society for Dermatologic Surgery, Dr. Tannous and her colleagues treated 14 patients with 23 biopsy-proven primary basal cell carcinomas (BCCs) located on their extremities and trunk. None of the patients had recurrent or infiltrative lesions. The BCCs ranged in diameter from 0.5 cm to 7 cm, and most were on the trunk.

All but two patients received four laser treatments at intervals of at least 2 weeks. The wavelength used was 595 nm at 15 J/cm2, with pulse durations of 3 milliseconds and a 7-mm minimally overlapping spot size with a single pass and no dynamic cooling.

Two weeks after the final laser treatment, the BCCs were removed by disk incision, and the tissue was stained using hematoxylin and eosin to observe the histologic response to treatment.

Interestingly, the two patients who did not receive the full four laser treatments—one received a single treatment and the other underwent three treatments—had no residual BCC in their excised lesions, Dr. Tannous said. A complete response was no residual basal cell carcinoma findings in excised tissue; incomplete response was evidence of any residual basal cells.

Of the 21 treated tumors, 13 (62%) completely responded. In a comparison, complete responses were seen in 2 of 21 control tumors that underwent diagnostic biopsy before being excised and were matched to the study lesions for size, histologic type, and location. "This [observation] proved that the response we're seeing is due to the selective laser treatment, and not due to the nonspecific inflammation related to the diagnostic biopsy," she explained.

Size appeared to be associated with the probability of a complete response to laser treatment. The average BCC was 1.1 cm in the complete responders and 2.8 cm in the incomplete responders.

Based on diameter, all small BCCs (under 0.7 cm) cleared completely; medium BCCs (0.7-1.4 cm) cleared completely in 92%; and large lesions (more than 1.4 cm) cleared in 22%.

At greater than 90%, the complete clearance rate for small and medium lesions treated by laser was significantly higher than the 61% rate seen in the matched controls.

"While these data show promise for the use of PDL [pulsed dye laser] in the treatment of both superficial and nodular basal cell carcinomas smaller than 1.5 cm, we cannot make clinical recommendations until we've completed a larger study with more patients," Dr. Tannous concluded.

Continued research should also demonstrate whether more treatment sessions would produce better results for larger BCCs.

Dr. Tannous reported having no conflicts of interest.

CHICAGO — Pulsed dye lasers may add a third option to the realm of treatments for superficial and nodular basal cell carcinomas less than 1.5 cm in diameter, according to Dr. Zeina Tannous, who performed a study of the treatment in 14 patients.

Unlike surgical excision or Mohs micrographic surgery, pulsed dye lasers selectively target vessels, said Dr. Tannous of Harvard Medical School, Boston, and chief of Mohs micrographic surgery at the Veterans Administration Hospital in Boston.

"Pulsed dye laser may allow for selective photothermolysis of pathological blood vessels and thus could be a nonsurgical treatment method for basal cell carcinomas, and this is important in patients with multiple tumors for whom surgery may be risky."

In her study, presented at the annual meeting of the American Society for Dermatologic Surgery, Dr. Tannous and her colleagues treated 14 patients with 23 biopsy-proven primary basal cell carcinomas (BCCs) located on their extremities and trunk. None of the patients had recurrent or infiltrative lesions. The BCCs ranged in diameter from 0.5 cm to 7 cm, and most were on the trunk.

All but two patients received four laser treatments at intervals of at least 2 weeks. The wavelength used was 595 nm at 15 J/cm2, with pulse durations of 3 milliseconds and a 7-mm minimally overlapping spot size with a single pass and no dynamic cooling.

Two weeks after the final laser treatment, the BCCs were removed by disk incision, and the tissue was stained using hematoxylin and eosin to observe the histologic response to treatment.

Interestingly, the two patients who did not receive the full four laser treatments—one received a single treatment and the other underwent three treatments—had no residual BCC in their excised lesions, Dr. Tannous said. A complete response was no residual basal cell carcinoma findings in excised tissue; incomplete response was evidence of any residual basal cells.

Of the 21 treated tumors, 13 (62%) completely responded. In a comparison, complete responses were seen in 2 of 21 control tumors that underwent diagnostic biopsy before being excised and were matched to the study lesions for size, histologic type, and location. "This [observation] proved that the response we're seeing is due to the selective laser treatment, and not due to the nonspecific inflammation related to the diagnostic biopsy," she explained.

Size appeared to be associated with the probability of a complete response to laser treatment. The average BCC was 1.1 cm in the complete responders and 2.8 cm in the incomplete responders.

Based on diameter, all small BCCs (under 0.7 cm) cleared completely; medium BCCs (0.7-1.4 cm) cleared completely in 92%; and large lesions (more than 1.4 cm) cleared in 22%.

At greater than 90%, the complete clearance rate for small and medium lesions treated by laser was significantly higher than the 61% rate seen in the matched controls.

"While these data show promise for the use of PDL [pulsed dye laser] in the treatment of both superficial and nodular basal cell carcinomas smaller than 1.5 cm, we cannot make clinical recommendations until we've completed a larger study with more patients," Dr. Tannous concluded.

Continued research should also demonstrate whether more treatment sessions would produce better results for larger BCCs.

Dr. Tannous reported having no conflicts of interest.

CHICAGO — Pulsed dye lasers may add a third option to the realm of treatments for superficial and nodular basal cell carcinomas less than 1.5 cm in diameter, according to Dr. Zeina Tannous, who performed a study of the treatment in 14 patients.

Unlike surgical excision or Mohs micrographic surgery, pulsed dye lasers selectively target vessels, said Dr. Tannous of Harvard Medical School, Boston, and chief of Mohs micrographic surgery at the Veterans Administration Hospital in Boston.

"Pulsed dye laser may allow for selective photothermolysis of pathological blood vessels and thus could be a nonsurgical treatment method for basal cell carcinomas, and this is important in patients with multiple tumors for whom surgery may be risky."

In her study, presented at the annual meeting of the American Society for Dermatologic Surgery, Dr. Tannous and her colleagues treated 14 patients with 23 biopsy-proven primary basal cell carcinomas (BCCs) located on their extremities and trunk. None of the patients had recurrent or infiltrative lesions. The BCCs ranged in diameter from 0.5 cm to 7 cm, and most were on the trunk.

All but two patients received four laser treatments at intervals of at least 2 weeks. The wavelength used was 595 nm at 15 J/cm2, with pulse durations of 3 milliseconds and a 7-mm minimally overlapping spot size with a single pass and no dynamic cooling.

Two weeks after the final laser treatment, the BCCs were removed by disk incision, and the tissue was stained using hematoxylin and eosin to observe the histologic response to treatment.

Interestingly, the two patients who did not receive the full four laser treatments—one received a single treatment and the other underwent three treatments—had no residual BCC in their excised lesions, Dr. Tannous said. A complete response was no residual basal cell carcinoma findings in excised tissue; incomplete response was evidence of any residual basal cells.

Of the 21 treated tumors, 13 (62%) completely responded. In a comparison, complete responses were seen in 2 of 21 control tumors that underwent diagnostic biopsy before being excised and were matched to the study lesions for size, histologic type, and location. "This [observation] proved that the response we're seeing is due to the selective laser treatment, and not due to the nonspecific inflammation related to the diagnostic biopsy," she explained.

Size appeared to be associated with the probability of a complete response to laser treatment. The average BCC was 1.1 cm in the complete responders and 2.8 cm in the incomplete responders.

Based on diameter, all small BCCs (under 0.7 cm) cleared completely; medium BCCs (0.7-1.4 cm) cleared completely in 92%; and large lesions (more than 1.4 cm) cleared in 22%.

At greater than 90%, the complete clearance rate for small and medium lesions treated by laser was significantly higher than the 61% rate seen in the matched controls.

"While these data show promise for the use of PDL [pulsed dye laser] in the treatment of both superficial and nodular basal cell carcinomas smaller than 1.5 cm, we cannot make clinical recommendations until we've completed a larger study with more patients," Dr. Tannous concluded.

Continued research should also demonstrate whether more treatment sessions would produce better results for larger BCCs.

Dr. Tannous reported having no conflicts of interest.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biological behaviors and risk profiles.

Yet, "with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist," said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not "histological curiosities," but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191-206, 261-79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%-10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. These would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant poten- tial. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), tumor size and depth of invasion, and presence or absence of perineural or hematolymphatic invasion.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. "When squamous cell carcinoma metastasizes, the literature just clumps [these cases]," but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, one study found that tumors less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624-7). Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr said. Perineural invasion is associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biological behaviors and risk profiles.

Yet, "with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist," said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not "histological curiosities," but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191-206, 261-79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%-10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. These would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant poten- tial. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), tumor size and depth of invasion, and presence or absence of perineural or hematolymphatic invasion.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. "When squamous cell carcinoma metastasizes, the literature just clumps [these cases]," but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, one study found that tumors less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624-7). Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr said. Perineural invasion is associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Cutaneous squamous cell carcinoma can take many forms, with vastly different biological behaviors and risk profiles.

Yet, "with relatively few exceptions, they have a tendency to simply be lumped by the nondermatologist clinician, the general surgeon, and the general pathologist," said Dr. Ronald Barr in calling for a comprehensive clinicopathologic classification of cutaneous SCC subtypes based on malignant potential.

Subtypes of SCC are not "histological curiosities," but distinct entities that offer important clues as to management and prognosis of individual patients, maintained Dr. Barr during a presentation to the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

A system of histologic subtypes of SCC has been proposed by Dr. Barr, professor emeritus of dermatology and pathology at the University of California, Irvine, and his colleagues (J. Cutan. Pathol. 2006;33:191-206, 261-79). The suggested subtypes include low-risk SCCs, which carry a less than 3% risk of metastasis; intermediate-risk SCCs, which have a 3%-10% risk of metastasis; high-risk SCCs, with a greater than 10% risk of metastasis; and SCCs of indeterminate malignant potential, explained Dr. Barr.

These subtype categories would include:

▸ Low-risk, invasive SCCs. These would include SCCs arising in sun-damaged skin of elderly patients (95% of cases), verrucous carcinoma and other human papillomavirus-related SCCs in immunocompetent patients, spindle cell SCC (unrelated to radiation exposure), and trichilemmal carcinoma.

▸ Intermediate-risk SCCs. Suggested category inclusions are acantholytic SCC, lymphoepitheliomalike carcinoma of the skin (LELCS), intraepidermal epithelioma (IEE), and Borst-Jadassohn tumor with invasion.

▸ High-risk SCCs. This subtype category would include invasive Bowen's disease; desmoplastic SCCs; malignant proliferating pilar tumor/cyst; de novo SCC; adenosquamous cell carcinoma; and SCC arising in association with radiation, burn scars, chronic conditions, or immunosuppression.

▸ SCCs of indeterminate malignant potential. Proposed subtypes for this category include signet-ring and clear cell SCC; pigmented, papillary, and follicular SCC; SCC arising in adnexal cysts; and possibly keratoacanthoma.

Dr. Barr acknowledged that many of the tumors he categorized as intermediate- or high-risk are rare, and there have been few studies to accurately determine their malignant poten- tial. However, this classification system would help to structure research by subtype and help to clarify future research by separating out entities that carry a higher risk potential than a superficially invasive, well-differentiated SCC arising within actinic keratoses on sun-damaged skin.

In addition to histologic subtypes, he called for more pathologic reporting of prognostic factors in individual SCC cases including the grade of differentiation (Broders' grades I-IV), tumor size and depth of invasion, and presence or absence of perineural or hematolymphatic invasion.

Fewer than 35% of patients with metastatic SCC survive for 5 years, in stark contrast to the generally excellent prognosis of SCC. "When squamous cell carcinoma metastasizes, the literature just clumps [these cases]," but clearly, individual characteristics make a difference, he said.

With regard to depth of invasion, one study found that tumors less than 2 mm thick never metastasized, those 2 mm to 6 mm metastasized at a rate of 4.5%, and those deeper than 6 mm metastasized at a rate of 15% (Am. J. Clin. Pathol. 1990;94:624-7). Low- versus high-grade differentiation carries a highly variable rate of metastasis as well (33% vs. 9%), Dr. Barr said. Perineural invasion is associated with rates of metastasis between 35% and 80%.

MONTEREY, CALIF. — Melanocytic tumors of unknown malignant potential represent some of the most difficult cases in pediatric dermatology, since little agreement exists about their diagnostic criteria, management, or outcome.

"They cause everyone, including pathologists, referring dermatologists, and surgeons, to lose sleep," said Dr. Susan Swetter, director of Stanford (Calif.) University's pigmented lesion and cutaneous melanoma clinic, at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dr. Swetter described the management of an 8-mm raised, blue-black nodule that appeared behind the right ear of an 11-year-old girl. Satellite blue-black macules appeared on the periphery of the lesion.

A partial 5-mm punch biopsy was reviewed by pathologists at Stanford; the University of California, San Francisco; and Massachusetts General Hospital, Boston. The conclusion was that the lesion was a melanocytic tumor of unknown malignant potential (MELTUMP) with decidedly mixed signals: no ulceration but a relatively high mitotic rate (4/mm2) and probable angiolymphatic invasion.

Differential diagnoses included a pigmented epithelioid melanocytoma, an agminated Spitz nevus, or a "low-grade" melanoma. The patient underwent a "fairly intuitive" comprehensive work-up, including a thorough personal and family history, a review of the timing and speed of growth of the lesion, and a total body skin examination and physical examination, including palpation of regional lymph node basins to assess for metastasis.

Melanoma experts agree that MELTUMP lesions should be completely excised, but the specifics about recommended margins remain hazy, Dr. Swetter explained. Some experts would decide to perform a wide excision in such a case, perhaps including sentinel lymph node biopsy, as if they were treating a melanoma.

At Stanford, where the patient was seen, the decision was made to take a 1-cm margin, narrower than the 2-cm margin that would be appropriate for a 3.7-mm melanoma, and to await the pathology results before deciding whether to perform a sentinel lymph node biopsy or lymph node dissection.

The histology on the wide excision specimen showed that the lesion was symmetrical and well circumscribed with a polypoid proliferation of darkly pigmented melanocytes and a mitotic rate "well below 1/mm2."

Dr. Swetter described the applicable histology images as revealing "deeply pigmented epithelial spindle cells and unmistakable angiolymphatic invasion."

"Our pathologists thought this was most consistent with a melanocytoma diagnosis," and noted its rarity as well as its "uncertain biological behavior," said Dr. Swetter.

A comparative genomic hybridization study was ordered from the UCSF laboratory, but results were estimated to take 6–8 weeks, a period of time that could compromise afferent lymphatic drainage from a scalp lesion and reduce the accuracy of the sentinel node biopsy.

After extensive discussions with the child's parents, the Stanford team elected to perform a sentinel lymph node biopsy but to await the outcome of the comparative genomic hybridization studies prior to performing complete lymph node dissection in the event that the sentinel node specimen was positive. A metastatic work-up with PET/CT scanning was performed "in part … to allay some of the parental concern about metastatic disease." Parenthetically, Dr. Swetter noted that such a scan would not generally be indicated in an asymptomatic patient with no signs of metastatic disease and would not preclude the possibility of a positive sentinel node biopsy. The scans were negative.

Two sentinel lymph nodes were identified and removed in the right cervical neck. One was positive for subcapsular and parenchymal metastatic foci of pigmented epithelioid melanocytoma and stained strongly positive for S100, MelanA, and HMB45.

Ironically, MELTUMP lesions have been associated with a very high rate of sentinel lymph node positivity in the two largest retrospective studies to date (44%–50%, compared with approximately 20% for typical melanomas with Breslow thickness greater than 1 mm).

However, the picture is confusing, because studies also associate atypical Spitz tumors with a very high survival rate despite apparent micrometastases.

In the case of Dr. Swetter's patient, a comparative genomic hybridization offered what appeared to be optimistic information, since the lesion contained aberrations on chromosome 11, a finding that has been exclusively associated with Spitz nevi in comparative studies with other benign nevi and melanomas. No complete lymph node dissection was performed and the patient has been followed for more than a year without evidence of recurrent disease.

Fatal outcomes have resulted in cases where several pathologists concurred with a diagnosis of Spitz nevus or atypical Spitzoid tumors, suggesting that these cases represented unrecognized melanoma, although this scenario does not appear to be the norm. The lesions should be completely excised, and treated similarly to melanomas when they are characterized by frank atypia or uncertain biologic behavior.

Until more information can be gathered from the national pediatric melanoma and melanocytic neoplasms database organized by Dr. Bruce Overbook at Case Western Reserve University in Cleveland, Dr. Swetter urged open and frank discussions among medical professionals and families about the diagnostic uncertainty regarding these lesions.

An 8-mm raised, blue-black nodule on an 11-year-old raised uncertainty among Stanford University specialists. Stanford University Departments of Dermatology and Pathology and the Melanoma Care Coalition, Pharmadura, LLC

MONTEREY, CALIF. — Melanocytic tumors of unknown malignant potential represent some of the most difficult cases in pediatric dermatology, since little agreement exists about their diagnostic criteria, management, or outcome.

"They cause everyone, including pathologists, referring dermatologists, and surgeons, to lose sleep," said Dr. Susan Swetter, director of Stanford (Calif.) University's pigmented lesion and cutaneous melanoma clinic, at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dr. Swetter described the management of an 8-mm raised, blue-black nodule that appeared behind the right ear of an 11-year-old girl. Satellite blue-black macules appeared on the periphery of the lesion.

A partial 5-mm punch biopsy was reviewed by pathologists at Stanford; the University of California, San Francisco; and Massachusetts General Hospital, Boston. The conclusion was that the lesion was a melanocytic tumor of unknown malignant potential (MELTUMP) with decidedly mixed signals: no ulceration but a relatively high mitotic rate (4/mm2) and probable angiolymphatic invasion.

Differential diagnoses included a pigmented epithelioid melanocytoma, an agminated Spitz nevus, or a "low-grade" melanoma. The patient underwent a "fairly intuitive" comprehensive work-up, including a thorough personal and family history, a review of the timing and speed of growth of the lesion, and a total body skin examination and physical examination, including palpation of regional lymph node basins to assess for metastasis.

Melanoma experts agree that MELTUMP lesions should be completely excised, but the specifics about recommended margins remain hazy, Dr. Swetter explained. Some experts would decide to perform a wide excision in such a case, perhaps including sentinel lymph node biopsy, as if they were treating a melanoma.

At Stanford, where the patient was seen, the decision was made to take a 1-cm margin, narrower than the 2-cm margin that would be appropriate for a 3.7-mm melanoma, and to await the pathology results before deciding whether to perform a sentinel lymph node biopsy or lymph node dissection.

The histology on the wide excision specimen showed that the lesion was symmetrical and well circumscribed with a polypoid proliferation of darkly pigmented melanocytes and a mitotic rate "well below 1/mm2."

Dr. Swetter described the applicable histology images as revealing "deeply pigmented epithelial spindle cells and unmistakable angiolymphatic invasion."

"Our pathologists thought this was most consistent with a melanocytoma diagnosis," and noted its rarity as well as its "uncertain biological behavior," said Dr. Swetter.

A comparative genomic hybridization study was ordered from the UCSF laboratory, but results were estimated to take 6–8 weeks, a period of time that could compromise afferent lymphatic drainage from a scalp lesion and reduce the accuracy of the sentinel node biopsy.

After extensive discussions with the child's parents, the Stanford team elected to perform a sentinel lymph node biopsy but to await the outcome of the comparative genomic hybridization studies prior to performing complete lymph node dissection in the event that the sentinel node specimen was positive. A metastatic work-up with PET/CT scanning was performed "in part … to allay some of the parental concern about metastatic disease." Parenthetically, Dr. Swetter noted that such a scan would not generally be indicated in an asymptomatic patient with no signs of metastatic disease and would not preclude the possibility of a positive sentinel node biopsy. The scans were negative.

Two sentinel lymph nodes were identified and removed in the right cervical neck. One was positive for subcapsular and parenchymal metastatic foci of pigmented epithelioid melanocytoma and stained strongly positive for S100, MelanA, and HMB45.

Ironically, MELTUMP lesions have been associated with a very high rate of sentinel lymph node positivity in the two largest retrospective studies to date (44%–50%, compared with approximately 20% for typical melanomas with Breslow thickness greater than 1 mm).

However, the picture is confusing, because studies also associate atypical Spitz tumors with a very high survival rate despite apparent micrometastases.

In the case of Dr. Swetter's patient, a comparative genomic hybridization offered what appeared to be optimistic information, since the lesion contained aberrations on chromosome 11, a finding that has been exclusively associated with Spitz nevi in comparative studies with other benign nevi and melanomas. No complete lymph node dissection was performed and the patient has been followed for more than a year without evidence of recurrent disease.

Fatal outcomes have resulted in cases where several pathologists concurred with a diagnosis of Spitz nevus or atypical Spitzoid tumors, suggesting that these cases represented unrecognized melanoma, although this scenario does not appear to be the norm. The lesions should be completely excised, and treated similarly to melanomas when they are characterized by frank atypia or uncertain biologic behavior.

Until more information can be gathered from the national pediatric melanoma and melanocytic neoplasms database organized by Dr. Bruce Overbook at Case Western Reserve University in Cleveland, Dr. Swetter urged open and frank discussions among medical professionals and families about the diagnostic uncertainty regarding these lesions.

An 8-mm raised, blue-black nodule on an 11-year-old raised uncertainty among Stanford University specialists. Stanford University Departments of Dermatology and Pathology and the Melanoma Care Coalition, Pharmadura, LLC

MONTEREY, CALIF. — Melanocytic tumors of unknown malignant potential represent some of the most difficult cases in pediatric dermatology, since little agreement exists about their diagnostic criteria, management, or outcome.

"They cause everyone, including pathologists, referring dermatologists, and surgeons, to lose sleep," said Dr. Susan Swetter, director of Stanford (Calif.) University's pigmented lesion and cutaneous melanoma clinic, at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dr. Swetter described the management of an 8-mm raised, blue-black nodule that appeared behind the right ear of an 11-year-old girl. Satellite blue-black macules appeared on the periphery of the lesion.

A partial 5-mm punch biopsy was reviewed by pathologists at Stanford; the University of California, San Francisco; and Massachusetts General Hospital, Boston. The conclusion was that the lesion was a melanocytic tumor of unknown malignant potential (MELTUMP) with decidedly mixed signals: no ulceration but a relatively high mitotic rate (4/mm2) and probable angiolymphatic invasion.

Differential diagnoses included a pigmented epithelioid melanocytoma, an agminated Spitz nevus, or a "low-grade" melanoma. The patient underwent a "fairly intuitive" comprehensive work-up, including a thorough personal and family history, a review of the timing and speed of growth of the lesion, and a total body skin examination and physical examination, including palpation of regional lymph node basins to assess for metastasis.

Melanoma experts agree that MELTUMP lesions should be completely excised, but the specifics about recommended margins remain hazy, Dr. Swetter explained. Some experts would decide to perform a wide excision in such a case, perhaps including sentinel lymph node biopsy, as if they were treating a melanoma.

At Stanford, where the patient was seen, the decision was made to take a 1-cm margin, narrower than the 2-cm margin that would be appropriate for a 3.7-mm melanoma, and to await the pathology results before deciding whether to perform a sentinel lymph node biopsy or lymph node dissection.

The histology on the wide excision specimen showed that the lesion was symmetrical and well circumscribed with a polypoid proliferation of darkly pigmented melanocytes and a mitotic rate "well below 1/mm2."

Dr. Swetter described the applicable histology images as revealing "deeply pigmented epithelial spindle cells and unmistakable angiolymphatic invasion."

"Our pathologists thought this was most consistent with a melanocytoma diagnosis," and noted its rarity as well as its "uncertain biological behavior," said Dr. Swetter.

A comparative genomic hybridization study was ordered from the UCSF laboratory, but results were estimated to take 6–8 weeks, a period of time that could compromise afferent lymphatic drainage from a scalp lesion and reduce the accuracy of the sentinel node biopsy.

After extensive discussions with the child's parents, the Stanford team elected to perform a sentinel lymph node biopsy but to await the outcome of the comparative genomic hybridization studies prior to performing complete lymph node dissection in the event that the sentinel node specimen was positive. A metastatic work-up with PET/CT scanning was performed "in part … to allay some of the parental concern about metastatic disease." Parenthetically, Dr. Swetter noted that such a scan would not generally be indicated in an asymptomatic patient with no signs of metastatic disease and would not preclude the possibility of a positive sentinel node biopsy. The scans were negative.

Two sentinel lymph nodes were identified and removed in the right cervical neck. One was positive for subcapsular and parenchymal metastatic foci of pigmented epithelioid melanocytoma and stained strongly positive for S100, MelanA, and HMB45.

Ironically, MELTUMP lesions have been associated with a very high rate of sentinel lymph node positivity in the two largest retrospective studies to date (44%–50%, compared with approximately 20% for typical melanomas with Breslow thickness greater than 1 mm).

However, the picture is confusing, because studies also associate atypical Spitz tumors with a very high survival rate despite apparent micrometastases.

In the case of Dr. Swetter's patient, a comparative genomic hybridization offered what appeared to be optimistic information, since the lesion contained aberrations on chromosome 11, a finding that has been exclusively associated with Spitz nevi in comparative studies with other benign nevi and melanomas. No complete lymph node dissection was performed and the patient has been followed for more than a year without evidence of recurrent disease.

Fatal outcomes have resulted in cases where several pathologists concurred with a diagnosis of Spitz nevus or atypical Spitzoid tumors, suggesting that these cases represented unrecognized melanoma, although this scenario does not appear to be the norm. The lesions should be completely excised, and treated similarly to melanomas when they are characterized by frank atypia or uncertain biologic behavior.

Until more information can be gathered from the national pediatric melanoma and melanocytic neoplasms database organized by Dr. Bruce Overbook at Case Western Reserve University in Cleveland, Dr. Swetter urged open and frank discussions among medical professionals and families about the diagnostic uncertainty regarding these lesions.

An 8-mm raised, blue-black nodule on an 11-year-old raised uncertainty among Stanford University specialists. Stanford University Departments of Dermatology and Pathology and the Melanoma Care Coalition, Pharmadura, LLC

ORLANDO — Vascular structures visualized on dermoscopy aid in the diagnosis of both benign and malignant nonpigmented tumors of the skin, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

In fact, associated vasculature should be evaluated carefully to avoid missing a malignancy, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

When using conventional dermoscopy for nonpigmented lesions, be careful about the amount of pressure applied because a blanching of the vessels can occur and impede diagnostic efforts. Also, consider using ultrasound gel rather than alcohol with dermoscopy, he suggested, because it helps prevent compression of vessels. (See box at right.)

This is important because special morphologic types of vessels are associated with different skin tumors. Various studies show which types of vessels are suggestive of which diagnoses, he said.

In nonpigmented basal cell carcinomas, arborizing vessels are a major feature visualized on dermoscopy, and these were shown in at least one study to have a 90% positive predictive value for basal cell carcinoma. Pink-white to white shiny areas and ulceration also are characteristic in these lesions.

With superficial basal cell carcinoma, two main dermoscopic features typically are observed: shiny pink to white structureless areas and short, fine telangiectasias.

Dr. Katz discussed other types of malignant lesions, along with their associated vasculature on dermoscopy:

PISquamous cell carcinoma in situ/Bowen's disease. These lesions are characterized by glomerular vessels and scaly surface on dermoscopy.

PISquamous cell carcinoma (more invasive types). Characterized by polymorphous vessels, which are mainly glomerular or hairpin vessels and are irregularly distributed and which have a whitish halo.

PIAmelanotic melanoma. Characterized by the presence of mainly dotted and linear irregular polymorphous vessels or by hairpin polymorphous vessels with milky-red globules/areas and ulceration. A whitish-pink background also may be seen on dermoscopy.

A rule of thumb is the more vessels seen, the more likely it is to be a malignant lesion, Dr. Katz said.

Vasculature visualized on dermoscopy is helpful for diagnosing benign nonpigmented lesions, including pyogenic granuloma (characterized by milky red homogenous areas separated with white intersecting lines with a white collarette at the periphery) and intradermal nevi (commalike vessels with a regular distribution throughout the lesion, a pink or pale structureless background, and sometimes pigmentary remnants).

Nonpigmented seborrheic keratosis also can be diagnosed with dermoscopy. It is characterized vascularly by regularly distributed hairpin loop vessels; dermoscopic features of keratinization; and dermoscopic features including comedolike opening, milialike cysts, sharp borders, fissures, and ridges. Yellow scaling and whitish halo also may be noted.

Other benign lesions that can be diagnosed include sebaceous hyperplasia—aggregated white to yellow central globularlike structures and surrounding, scarcely branching crown vessels at the periphery that never cross the center of the neoplasm—and Spitz nevus, which is characterized by dotted vessels, regular distribution, and a pink background, Dr. Katz said.

Dermoscopy of a malignant neoplasm reveals multiple arborizing vessels on a pink, whiteshiny background. Courtesy Dr. Brian Katz

Ultrasound Gel a Better Choice in Some Situations

Research on the use of dermoscopy has shown that although alcohol is the "best all around" fluid to use for dermoscopy, ultrasound gel is a better option in some instances, Dr. Katz noted.

For examining melanonychia of the nail plate, gel works best. Similarly, for nonpigmented tumors of the skin, in which visualization of the vasculature is important for making a correct diagnosis, gel helps mitigate the effects of some of the pressure that is applied with conventional contact dermoscopy.

In a comparison of contact dermoscopy with gel versus alcohol for a malignant melanoma, the gel clearly allowed much better visualization of the vasculature, while the alcohol allowed more compression—and thus blanching—of the vessels, he said.

The effect was strictly caused by the pressure applied, he said at the meeting, noting that pressure should be minimal with contact dermoscopy.

An option to circumvent this problem altogether is to use a polarized dermatoscope in noncontact mode, which has been shown to be the best option for visualizing blood vessels, Dr. Katz said.

Dermoscopy with ultrasound gel (left) allows for better visualization than with alcohol (right) because there is less vessel compression. PHOTOS COURTESY DR. HAROLD RABINOVITZ

ORLANDO — Vascular structures visualized on dermoscopy aid in the diagnosis of both benign and malignant nonpigmented tumors of the skin, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

In fact, associated vasculature should be evaluated carefully to avoid missing a malignancy, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

When using conventional dermoscopy for nonpigmented lesions, be careful about the amount of pressure applied because a blanching of the vessels can occur and impede diagnostic efforts. Also, consider using ultrasound gel rather than alcohol with dermoscopy, he suggested, because it helps prevent compression of vessels. (See box at right.)

This is important because special morphologic types of vessels are associated with different skin tumors. Various studies show which types of vessels are suggestive of which diagnoses, he said.

In nonpigmented basal cell carcinomas, arborizing vessels are a major feature visualized on dermoscopy, and these were shown in at least one study to have a 90% positive predictive value for basal cell carcinoma. Pink-white to white shiny areas and ulceration also are characteristic in these lesions.

With superficial basal cell carcinoma, two main dermoscopic features typically are observed: shiny pink to white structureless areas and short, fine telangiectasias.

Dr. Katz discussed other types of malignant lesions, along with their associated vasculature on dermoscopy:

PISquamous cell carcinoma in situ/Bowen's disease. These lesions are characterized by glomerular vessels and scaly surface on dermoscopy.

PISquamous cell carcinoma (more invasive types). Characterized by polymorphous vessels, which are mainly glomerular or hairpin vessels and are irregularly distributed and which have a whitish halo.

PIAmelanotic melanoma. Characterized by the presence of mainly dotted and linear irregular polymorphous vessels or by hairpin polymorphous vessels with milky-red globules/areas and ulceration. A whitish-pink background also may be seen on dermoscopy.

A rule of thumb is the more vessels seen, the more likely it is to be a malignant lesion, Dr. Katz said.

Vasculature visualized on dermoscopy is helpful for diagnosing benign nonpigmented lesions, including pyogenic granuloma (characterized by milky red homogenous areas separated with white intersecting lines with a white collarette at the periphery) and intradermal nevi (commalike vessels with a regular distribution throughout the lesion, a pink or pale structureless background, and sometimes pigmentary remnants).

Nonpigmented seborrheic keratosis also can be diagnosed with dermoscopy. It is characterized vascularly by regularly distributed hairpin loop vessels; dermoscopic features of keratinization; and dermoscopic features including comedolike opening, milialike cysts, sharp borders, fissures, and ridges. Yellow scaling and whitish halo also may be noted.

Other benign lesions that can be diagnosed include sebaceous hyperplasia—aggregated white to yellow central globularlike structures and surrounding, scarcely branching crown vessels at the periphery that never cross the center of the neoplasm—and Spitz nevus, which is characterized by dotted vessels, regular distribution, and a pink background, Dr. Katz said.

Dermoscopy of a malignant neoplasm reveals multiple arborizing vessels on a pink, whiteshiny background. Courtesy Dr. Brian Katz

Ultrasound Gel a Better Choice in Some Situations

Research on the use of dermoscopy has shown that although alcohol is the "best all around" fluid to use for dermoscopy, ultrasound gel is a better option in some instances, Dr. Katz noted.

For examining melanonychia of the nail plate, gel works best. Similarly, for nonpigmented tumors of the skin, in which visualization of the vasculature is important for making a correct diagnosis, gel helps mitigate the effects of some of the pressure that is applied with conventional contact dermoscopy.

In a comparison of contact dermoscopy with gel versus alcohol for a malignant melanoma, the gel clearly allowed much better visualization of the vasculature, while the alcohol allowed more compression—and thus blanching—of the vessels, he said.

The effect was strictly caused by the pressure applied, he said at the meeting, noting that pressure should be minimal with contact dermoscopy.

An option to circumvent this problem altogether is to use a polarized dermatoscope in noncontact mode, which has been shown to be the best option for visualizing blood vessels, Dr. Katz said.

Dermoscopy with ultrasound gel (left) allows for better visualization than with alcohol (right) because there is less vessel compression. PHOTOS COURTESY DR. HAROLD RABINOVITZ

ORLANDO — Vascular structures visualized on dermoscopy aid in the diagnosis of both benign and malignant nonpigmented tumors of the skin, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

In fact, associated vasculature should be evaluated carefully to avoid missing a malignancy, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

When using conventional dermoscopy for nonpigmented lesions, be careful about the amount of pressure applied because a blanching of the vessels can occur and impede diagnostic efforts. Also, consider using ultrasound gel rather than alcohol with dermoscopy, he suggested, because it helps prevent compression of vessels. (See box at right.)

This is important because special morphologic types of vessels are associated with different skin tumors. Various studies show which types of vessels are suggestive of which diagnoses, he said.

In nonpigmented basal cell carcinomas, arborizing vessels are a major feature visualized on dermoscopy, and these were shown in at least one study to have a 90% positive predictive value for basal cell carcinoma. Pink-white to white shiny areas and ulceration also are characteristic in these lesions.

With superficial basal cell carcinoma, two main dermoscopic features typically are observed: shiny pink to white structureless areas and short, fine telangiectasias.

Dr. Katz discussed other types of malignant lesions, along with their associated vasculature on dermoscopy:

PISquamous cell carcinoma in situ/Bowen's disease. These lesions are characterized by glomerular vessels and scaly surface on dermoscopy.

PISquamous cell carcinoma (more invasive types). Characterized by polymorphous vessels, which are mainly glomerular or hairpin vessels and are irregularly distributed and which have a whitish halo.

PIAmelanotic melanoma. Characterized by the presence of mainly dotted and linear irregular polymorphous vessels or by hairpin polymorphous vessels with milky-red globules/areas and ulceration. A whitish-pink background also may be seen on dermoscopy.

A rule of thumb is the more vessels seen, the more likely it is to be a malignant lesion, Dr. Katz said.

Vasculature visualized on dermoscopy is helpful for diagnosing benign nonpigmented lesions, including pyogenic granuloma (characterized by milky red homogenous areas separated with white intersecting lines with a white collarette at the periphery) and intradermal nevi (commalike vessels with a regular distribution throughout the lesion, a pink or pale structureless background, and sometimes pigmentary remnants).

Nonpigmented seborrheic keratosis also can be diagnosed with dermoscopy. It is characterized vascularly by regularly distributed hairpin loop vessels; dermoscopic features of keratinization; and dermoscopic features including comedolike opening, milialike cysts, sharp borders, fissures, and ridges. Yellow scaling and whitish halo also may be noted.

Other benign lesions that can be diagnosed include sebaceous hyperplasia—aggregated white to yellow central globularlike structures and surrounding, scarcely branching crown vessels at the periphery that never cross the center of the neoplasm—and Spitz nevus, which is characterized by dotted vessels, regular distribution, and a pink background, Dr. Katz said.

Dermoscopy of a malignant neoplasm reveals multiple arborizing vessels on a pink, whiteshiny background. Courtesy Dr. Brian Katz

Ultrasound Gel a Better Choice in Some Situations

Research on the use of dermoscopy has shown that although alcohol is the "best all around" fluid to use for dermoscopy, ultrasound gel is a better option in some instances, Dr. Katz noted.

For examining melanonychia of the nail plate, gel works best. Similarly, for nonpigmented tumors of the skin, in which visualization of the vasculature is important for making a correct diagnosis, gel helps mitigate the effects of some of the pressure that is applied with conventional contact dermoscopy.

In a comparison of contact dermoscopy with gel versus alcohol for a malignant melanoma, the gel clearly allowed much better visualization of the vasculature, while the alcohol allowed more compression—and thus blanching—of the vessels, he said.

The effect was strictly caused by the pressure applied, he said at the meeting, noting that pressure should be minimal with contact dermoscopy.

An option to circumvent this problem altogether is to use a polarized dermatoscope in noncontact mode, which has been shown to be the best option for visualizing blood vessels, Dr. Katz said.

Dermoscopy with ultrasound gel (left) allows for better visualization than with alcohol (right) because there is less vessel compression. PHOTOS COURTESY DR. HAROLD RABINOVITZ

ORLANDO — The field of dermoscopy is expanding rapidly, as demonstrated both by the increase in published papers on the topic in recent years and by the increasing number of uses for the technology, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

A recent study noted that 450 papers were published on the topic between 2000 and 2005, compared with 100 between 1987 and 1999, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

His own review of more recent literature showed that about 250 papers on dermoscopy were published in the last year alone.

Additionally, dermoscopy now is being used to predict and/or monitor treatment response in a variety of conditions.

Patients being treated with topical corticosteroids for lichen planus and psoriasis, for example, are being monitored for early signs of atrophy, according to Dr. Katz.

It also appears that patterns seen on dermoscopy in port-wine stains of the face can predict response to pulsed dye laser treatment, Dr. Katz said.

One study of 33 children demonstrated that those with a superficial pattern involving multiple dotted or globularlike vessels were more likely to have a good response. The children with deeper patterns involving linear vessels, which were sometimes reticular in appearance, had much poorer response (Pediatr. Dermatol. 2004;21:589–96).

The study also showed that an undefined pattern on dermoscopy was an indication that no further response would be achieved with treatment. This type of finding typically occurred after multiple treatments, and the investigators suggested it should mark the end point of treatment.

Dermoscopy has been shown to be useful in guiding resection of lentigo maligna of the head and neck.

In a study of 26 patients with lesions that clinically appeared to have an uninvolved border, dermoscopy distinguished those with an anular pattern that histologically corresponded to melanoma in situ from those with findings indicative of the melanocytic hyperplasia commonly seen in sun-damaged skin (Arch. Dermatol. 2004;140:1095–110).

More recently, dermoscopy has been reported to be useful for monitoring the progress of patients treated with tazarotene for superficial basal cell carcinomas.

In a study of 41 patients, with slightly more than half achieving a complete response, dermoscopy showed progressive loss of dermoscopic structures over the course of treatment until the end point was achieved and all leaflike areas, arborizing vessels, and pink/white background had resolved (Dermatol. Surg. 2005;31:217–20).

In a case report published in 2006, dermoscopy was used successfully to monitor the response to imiquimod in a patient treated for lentigo maligna. Over a 12-week treatment course, progressive loss of dermoscopic features of facial lentigo maligna, such as asymmetrically pigmented hair follicle openings and rhomboidal structures around hair follicles, all had resolved (Arch. Dermatol. 2006;142:530–1). The patient was followed for 2 years with no recurrence, Dr. Katz said.

ORLANDO — The field of dermoscopy is expanding rapidly, as demonstrated both by the increase in published papers on the topic in recent years and by the increasing number of uses for the technology, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

A recent study noted that 450 papers were published on the topic between 2000 and 2005, compared with 100 between 1987 and 1999, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

His own review of more recent literature showed that about 250 papers on dermoscopy were published in the last year alone.

Additionally, dermoscopy now is being used to predict and/or monitor treatment response in a variety of conditions.

Patients being treated with topical corticosteroids for lichen planus and psoriasis, for example, are being monitored for early signs of atrophy, according to Dr. Katz.

It also appears that patterns seen on dermoscopy in port-wine stains of the face can predict response to pulsed dye laser treatment, Dr. Katz said.

One study of 33 children demonstrated that those with a superficial pattern involving multiple dotted or globularlike vessels were more likely to have a good response. The children with deeper patterns involving linear vessels, which were sometimes reticular in appearance, had much poorer response (Pediatr. Dermatol. 2004;21:589–96).

The study also showed that an undefined pattern on dermoscopy was an indication that no further response would be achieved with treatment. This type of finding typically occurred after multiple treatments, and the investigators suggested it should mark the end point of treatment.

Dermoscopy has been shown to be useful in guiding resection of lentigo maligna of the head and neck.

In a study of 26 patients with lesions that clinically appeared to have an uninvolved border, dermoscopy distinguished those with an anular pattern that histologically corresponded to melanoma in situ from those with findings indicative of the melanocytic hyperplasia commonly seen in sun-damaged skin (Arch. Dermatol. 2004;140:1095–110).

More recently, dermoscopy has been reported to be useful for monitoring the progress of patients treated with tazarotene for superficial basal cell carcinomas.

In a study of 41 patients, with slightly more than half achieving a complete response, dermoscopy showed progressive loss of dermoscopic structures over the course of treatment until the end point was achieved and all leaflike areas, arborizing vessels, and pink/white background had resolved (Dermatol. Surg. 2005;31:217–20).

In a case report published in 2006, dermoscopy was used successfully to monitor the response to imiquimod in a patient treated for lentigo maligna. Over a 12-week treatment course, progressive loss of dermoscopic features of facial lentigo maligna, such as asymmetrically pigmented hair follicle openings and rhomboidal structures around hair follicles, all had resolved (Arch. Dermatol. 2006;142:530–1). The patient was followed for 2 years with no recurrence, Dr. Katz said.

ORLANDO — The field of dermoscopy is expanding rapidly, as demonstrated both by the increase in published papers on the topic in recent years and by the increasing number of uses for the technology, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

A recent study noted that 450 papers were published on the topic between 2000 and 2005, compared with 100 between 1987 and 1999, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

His own review of more recent literature showed that about 250 papers on dermoscopy were published in the last year alone.

Additionally, dermoscopy now is being used to predict and/or monitor treatment response in a variety of conditions.

Patients being treated with topical corticosteroids for lichen planus and psoriasis, for example, are being monitored for early signs of atrophy, according to Dr. Katz.

It also appears that patterns seen on dermoscopy in port-wine stains of the face can predict response to pulsed dye laser treatment, Dr. Katz said.

One study of 33 children demonstrated that those with a superficial pattern involving multiple dotted or globularlike vessels were more likely to have a good response. The children with deeper patterns involving linear vessels, which were sometimes reticular in appearance, had much poorer response (Pediatr. Dermatol. 2004;21:589–96).

The study also showed that an undefined pattern on dermoscopy was an indication that no further response would be achieved with treatment. This type of finding typically occurred after multiple treatments, and the investigators suggested it should mark the end point of treatment.

Dermoscopy has been shown to be useful in guiding resection of lentigo maligna of the head and neck.

In a study of 26 patients with lesions that clinically appeared to have an uninvolved border, dermoscopy distinguished those with an anular pattern that histologically corresponded to melanoma in situ from those with findings indicative of the melanocytic hyperplasia commonly seen in sun-damaged skin (Arch. Dermatol. 2004;140:1095–110).

More recently, dermoscopy has been reported to be useful for monitoring the progress of patients treated with tazarotene for superficial basal cell carcinomas.

In a study of 41 patients, with slightly more than half achieving a complete response, dermoscopy showed progressive loss of dermoscopic structures over the course of treatment until the end point was achieved and all leaflike areas, arborizing vessels, and pink/white background had resolved (Dermatol. Surg. 2005;31:217–20).

In a case report published in 2006, dermoscopy was used successfully to monitor the response to imiquimod in a patient treated for lentigo maligna. Over a 12-week treatment course, progressive loss of dermoscopic features of facial lentigo maligna, such as asymmetrically pigmented hair follicle openings and rhomboidal structures around hair follicles, all had resolved (Arch. Dermatol. 2006;142:530–1). The patient was followed for 2 years with no recurrence, Dr. Katz said.

ZURICH — In vivo confocal laser scanning microscopy is a useful diagnostic tool for pigmented skin lesions that are clinically and dermoscopically equivocal, Dr. Verena Ahlgrimm-Siess said at the annual meeting of the European Society for Dermatological Research.

"The ability to noninvasively analyze the architecture and cytomorphology of pigmented skin lesions permits a preliminary diagnostic evaluation and allows, in context with the clinical and dermoscopic impression, a judgment on the need for biopsy or excision for definitive diagnosis," according to Dr. Ahlgrimm-Siess of the Medical University of Graz (Austria).

Early detection of melanoma is one of the greatest challenges in dermatology, according to Dr. Ahlgrimm-Siess. Studies indicate the sensitivity of clinical diagnosis with the unaided eye is about 65%.

Dermoscopy improves diagnostic accuracy, but it takes a fair amount of time and practice to become skillful. The 10x magnification is another limitation.

Confocal laser scanning microscopy permits real-time noninvasive visualization of epidermal and dermal microanatomic structures and cellular details at a resolution comparable to that obtained in examination of histologic specimens under a conventional microscope.

The novel imaging technology utilizes a near-infrared diode laser at 830 nm wavelength and sufficiently low power—less than 35 mW at the tissue level—that no tissue damage occurs.

Physicians can be taught to use confocal laser scanning microscopy in a 1-hour presentation.

Among the diagnostic features of the laser scanning technique that have proved most helpful to physicians in distinguishing melanomas are monomorphic melanocytic cells, disarray of the melanocytic architecture, and bright collagen fiber bundles.

In a prior study, investigators reported 97.6% sensitivity and 88.2% specificity for confocal laser scanning microscopy in discriminating malignant from benign pigmented skin lesions (J. Invest. Dermatol. 2005;124:493–8) and a positive predictive value of 94.2% in another (Cancer 2006;107:193–200). However, these were lesions in which the distinction using conventional means was relatively clear cut, noted Dr. Ahlgrimm-Siess.

The physician presented a more clinically realistic study involving 50 challenging equivocal pigmented lesions in which melanoma could not be ruled out clinically or dermoscopically. There were 16 melanomas, 3 basal cell carcinomas, 25 melanocytic nevi, and 6 nonmelanocytic pigmented lesions.

Relying solely on the laser scanning microscope images, blinded physicians missed two melanomas, for a diagnostic sensitivity of 89.4% and a specificity of 64.5%.

However, with access to the clinical and dermoscopic images as well as laser scanning microscopy, the specificity climbed to 87% while the sensitivity remained at 89.4%.

Discrimination of benign nevi from early melanoma in situ up to 0.75 mm in thickness could be made in 9 of 11 cases with the laser scanning microscopy alone, for a sensitivity of 81.8% and a specificity of 84%, Dr. Ahlgrimm-Siess added.

The jump in diagnostic specificity from 64.5% with laser scanning microscopy alone to 87% in combination with dermoscopic and clinical evaluation wasn't enough to satisfy the session cochair, Dr. Hywel Williams.

He indicated that he doesn't consider the laser scanning technique ready for prime time as a means of sparing patients from undergoing negative skin biopsies.

"I would be, as a clinician, certainly not happy to be missing 13% or 14% of malignant lesions," said Dr. Williams, professor of dermato-epidemiology at the University of Nottingham (England).

ZURICH — In vivo confocal laser scanning microscopy is a useful diagnostic tool for pigmented skin lesions that are clinically and dermoscopically equivocal, Dr. Verena Ahlgrimm-Siess said at the annual meeting of the European Society for Dermatological Research.

"The ability to noninvasively analyze the architecture and cytomorphology of pigmented skin lesions permits a preliminary diagnostic evaluation and allows, in context with the clinical and dermoscopic impression, a judgment on the need for biopsy or excision for definitive diagnosis," according to Dr. Ahlgrimm-Siess of the Medical University of Graz (Austria).

Early detection of melanoma is one of the greatest challenges in dermatology, according to Dr. Ahlgrimm-Siess. Studies indicate the sensitivity of clinical diagnosis with the unaided eye is about 65%.

Dermoscopy improves diagnostic accuracy, but it takes a fair amount of time and practice to become skillful. The 10x magnification is another limitation.

Confocal laser scanning microscopy permits real-time noninvasive visualization of epidermal and dermal microanatomic structures and cellular details at a resolution comparable to that obtained in examination of histologic specimens under a conventional microscope.

The novel imaging technology utilizes a near-infrared diode laser at 830 nm wavelength and sufficiently low power—less than 35 mW at the tissue level—that no tissue damage occurs.

Physicians can be taught to use confocal laser scanning microscopy in a 1-hour presentation.

Among the diagnostic features of the laser scanning technique that have proved most helpful to physicians in distinguishing melanomas are monomorphic melanocytic cells, disarray of the melanocytic architecture, and bright collagen fiber bundles.

In a prior study, investigators reported 97.6% sensitivity and 88.2% specificity for confocal laser scanning microscopy in discriminating malignant from benign pigmented skin lesions (J. Invest. Dermatol. 2005;124:493–8) and a positive predictive value of 94.2% in another (Cancer 2006;107:193–200). However, these were lesions in which the distinction using conventional means was relatively clear cut, noted Dr. Ahlgrimm-Siess.

The physician presented a more clinically realistic study involving 50 challenging equivocal pigmented lesions in which melanoma could not be ruled out clinically or dermoscopically. There were 16 melanomas, 3 basal cell carcinomas, 25 melanocytic nevi, and 6 nonmelanocytic pigmented lesions.

Relying solely on the laser scanning microscope images, blinded physicians missed two melanomas, for a diagnostic sensitivity of 89.4% and a specificity of 64.5%.

However, with access to the clinical and dermoscopic images as well as laser scanning microscopy, the specificity climbed to 87% while the sensitivity remained at 89.4%.

Discrimination of benign nevi from early melanoma in situ up to 0.75 mm in thickness could be made in 9 of 11 cases with the laser scanning microscopy alone, for a sensitivity of 81.8% and a specificity of 84%, Dr. Ahlgrimm-Siess added.

The jump in diagnostic specificity from 64.5% with laser scanning microscopy alone to 87% in combination with dermoscopic and clinical evaluation wasn't enough to satisfy the session cochair, Dr. Hywel Williams.

He indicated that he doesn't consider the laser scanning technique ready for prime time as a means of sparing patients from undergoing negative skin biopsies.

"I would be, as a clinician, certainly not happy to be missing 13% or 14% of malignant lesions," said Dr. Williams, professor of dermato-epidemiology at the University of Nottingham (England).

ZURICH — In vivo confocal laser scanning microscopy is a useful diagnostic tool for pigmented skin lesions that are clinically and dermoscopically equivocal, Dr. Verena Ahlgrimm-Siess said at the annual meeting of the European Society for Dermatological Research.

"The ability to noninvasively analyze the architecture and cytomorphology of pigmented skin lesions permits a preliminary diagnostic evaluation and allows, in context with the clinical and dermoscopic impression, a judgment on the need for biopsy or excision for definitive diagnosis," according to Dr. Ahlgrimm-Siess of the Medical University of Graz (Austria).

Early detection of melanoma is one of the greatest challenges in dermatology, according to Dr. Ahlgrimm-Siess. Studies indicate the sensitivity of clinical diagnosis with the unaided eye is about 65%.

Dermoscopy improves diagnostic accuracy, but it takes a fair amount of time and practice to become skillful. The 10x magnification is another limitation.

Confocal laser scanning microscopy permits real-time noninvasive visualization of epidermal and dermal microanatomic structures and cellular details at a resolution comparable to that obtained in examination of histologic specimens under a conventional microscope.

The novel imaging technology utilizes a near-infrared diode laser at 830 nm wavelength and sufficiently low power—less than 35 mW at the tissue level—that no tissue damage occurs.

Physicians can be taught to use confocal laser scanning microscopy in a 1-hour presentation.

Among the diagnostic features of the laser scanning technique that have proved most helpful to physicians in distinguishing melanomas are monomorphic melanocytic cells, disarray of the melanocytic architecture, and bright collagen fiber bundles.

In a prior study, investigators reported 97.6% sensitivity and 88.2% specificity for confocal laser scanning microscopy in discriminating malignant from benign pigmented skin lesions (J. Invest. Dermatol. 2005;124:493–8) and a positive predictive value of 94.2% in another (Cancer 2006;107:193–200). However, these were lesions in which the distinction using conventional means was relatively clear cut, noted Dr. Ahlgrimm-Siess.

The physician presented a more clinically realistic study involving 50 challenging equivocal pigmented lesions in which melanoma could not be ruled out clinically or dermoscopically. There were 16 melanomas, 3 basal cell carcinomas, 25 melanocytic nevi, and 6 nonmelanocytic pigmented lesions.

Relying solely on the laser scanning microscope images, blinded physicians missed two melanomas, for a diagnostic sensitivity of 89.4% and a specificity of 64.5%.

However, with access to the clinical and dermoscopic images as well as laser scanning microscopy, the specificity climbed to 87% while the sensitivity remained at 89.4%.

Discrimination of benign nevi from early melanoma in situ up to 0.75 mm in thickness could be made in 9 of 11 cases with the laser scanning microscopy alone, for a sensitivity of 81.8% and a specificity of 84%, Dr. Ahlgrimm-Siess added.

The jump in diagnostic specificity from 64.5% with laser scanning microscopy alone to 87% in combination with dermoscopic and clinical evaluation wasn't enough to satisfy the session cochair, Dr. Hywel Williams.

He indicated that he doesn't consider the laser scanning technique ready for prime time as a means of sparing patients from undergoing negative skin biopsies.

"I would be, as a clinician, certainly not happy to be missing 13% or 14% of malignant lesions," said Dr. Williams, professor of dermato-epidemiology at the University of Nottingham (England).