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Dermoscopic Evaluation of Nodular Melanoma

Scott W. Menzies, MBBS, PhD; Fergal J. Moloney, MD; Karen Byth, PhD; Michelle Avramidis, BSc; Giuseppe Argenziano, MD; Iris Zalaudek, MD; Ralph P. Braun, MD; Josep Malvehy, MD; Susana Puig, MD; Harold S. Rabinovitz, MD; Margaret Oliviero, ARNP; Horacio Cabo, MD; Riccardo Bono, MD; Maria A. Pizzichetta, MD; Magdalena Claeson, MD; Daniel C. Gaffney, MBBS; H. Peter Soyer, MD; Ignazio Stanganelli, MD; Richard A. Scolyer, MD; Pascale Guitera, MD, PhD; John Kelly, MD; Olivia McCurdy, MBBS; Alex Llambrich, MD; Ashfaq A. Marghoob, MD; Pedro Zaballos, MD; Herbert M. Kirchesch, MD; Domenico Piccolo, MD; Jonathan Bowling, MBChB; Luc Thomas, MD, PhD; Karin Terstappen, MD, PhD; Masaru Tanaka, MD; Giovanni Pellacani, MD; Gianluca Pagnanelli, MD; Giovanni Ghigliotti, MD; Blanca Carlos Ortega, MD; Greg Crafter, MBBS; Ana María Perusquía Ortiz, MD; Isabelle Tromme, MD; Isil Kilinc Karaarslan, MD; Fezal Ozdemir, MD; Anthony Tam, MBChB; Christian Landi, MD; Peter Norton, MBBS; Nida Kaçar, MD; Lidia Rudnicka, MD, PhD; Monika Slowinska, MD, PhD; Olga Simionescu, MD, PhD; Alessandro Di Stefani, MD; Elliot Coates, MBBS, BSc; Juergen Kreusch, PhD, MD
JAMA Dermatol. 2013;149(6):699-709. doi:10.1001/jamadermatol.2013.2466.
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Importance Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical.

Objective To determine the dermoscopy features of NM.

Design Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes.

Setting Predominantly hospital-based clinics from 5 continents.

Main Outcome Measures Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma.

Results Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM.

Conclusions and Relevance When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

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Figure 1. Flowchart of included lesions. IDS indicates International Dermoscopy Society; NM, nodular melanoma.

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Figure 2. Typical nodular pigmented melanoma. A, This asymmetrical pigmented nodule has the significant positive predictors of blue-white veil, multiple (5-6) colors (scored from tan, dark brown, red, blue, gray, and black), irregular blotches, irregular brown dots and globules, and black color (Breslow thickness, 4.5 mm). B, This asymmetrical pigmented nodule has a blue-white veil, irregular blotches, and irregular dots and globules, some of which are black, that are found both in a central and peripheral position (Breslow thickness, 5.0 mm). C, This asymmetrical pigmented nodule has a blue-white veil, multiple brown dots (white arrows), 5 or 6 colors, peripheral black dots and globules, milky red and pink areas, and irregular blotches (Breslow thickness, 6.7 mm). D, This asymmetrical pigmented nodule has peripheral black dots and globules, irregular dots and globules (size and distribution), pseudopods (arrow), and black color (Breslow thickness, 1.2 mm).

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Figure 3. Symmetrical pigmented nodular melanoma. Although most nodular pigmented melanoma lesions have asymmetrical pigmented patterns, 5.8% have symmetrical pigmentation, as seen here. The Breslow thicknesses are A, 1.7 mm; B, 1.0 mm; C, 0.9 mm; and D, 4.3 mm.

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Figure 4. Amelanotic/hypomelanotic nodular melanoma (NM). A, This hypomelanotic nodule has atypical vasculature shown as combinations of dotted (thick arrow), linear irregular (thin black arrows), and hairpin vessels (white arrows) (Breslow thickness, 2.2 mm). B, This lesion has a central white patch mimicking a dermatofibroma. A total of 12.9% of amelanotic/hypomelanotic NMs were reported to have central white patches. In this case the ulceration led to a suspicion of malignancy (Breslow thickness, 2.2 mm). C, This small-diameter hypomelanotic (light-colored) nodule has asymmetrical pigmentation with areas of blue-white veil (Breslow thickness, 0.94 mm). D, This hypomelanotic lesion has fine, predominantly linear irregular vessels at the periphery of the nodule (Breslow thickness, 1.87 mm). E, This amelanotic nodule has diffuse hairpin vessels throughout the lesion in a symmetrical pattern (Breslow thickness, 2.0 mm).




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