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Original Investigation |

Validity and Reliability of Dermoscopic Criteria Used to Differentiate Nevi From Melanoma A Web-Based International Dermoscopy Society Study

Cristina Carrera, MD, PhD1,2; Michael A. Marchetti, MD1; Stephen W. Dusza, DrPH1; Giuseppe Argenziano, MD3; Ralph P. Braun, MD4; Allan C. Halpern, MD1; Natalia Jaimes, MD5; Harald J. Kittler, MD6; Josep Malvehy, MD2; Scott W. Menzies, MBBS, PhD7,8; Giovanni Pellacani, MD9; Susana Puig, MD2; Harold S. Rabinovitz, MD10; Alon Scope, MD11; H. Peter Soyer, MD12,13; Wilhelm Stolz, MD14; Rainer Hofmann-Wellenhof, MD15; Iris Zalaudek, MD15; Ashfaq A. Marghoob, MD1
[+] Author Affiliations
1Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
2Melanoma Unit, Department of Dermatology, Hospital Clinic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigacion Biomedica en red de enfermedades raras, Barcelona, Spain
3Dermatology Unit, Second University of Naples, Naples, Italy
4Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
5Dermatology Service, Aurora Skin Cancer Center, Universidad Pontificia Bolivariana, Medellín, Colombia
6Department of Dermatology, Medical University of Vienna, Vienna, Austria
7Sydney Melanoma Diagnostic Centre, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, Australia
8Discipline of Dermatology, The University of Sydney, New South Wales, Australia
9Center for Environmental, Genetic, and Nutritional Epidemiology, Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
10Skin and Cancer Associates, Plantation, Florida
11Department of Dermatology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
12Dermatology Research Centre, The University of Queensland, Brisbane, Queensland, Australia
13School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia
14Clinic for Dermatology, Allergology, and Environmental Medicine, Klinik Thalkirchner Straße Städt, Klinikum München GmbH, Munich, Germany
15Department of Dermatology, Medical University of Graz, Graz, Austria
JAMA Dermatol. 2016;152(7):798-806. doi:10.1001/jamadermatol.2016.0624.
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Importance  The comparative diagnostic performance of dermoscopic algorithms and their individual criteria are not well studied.

Objectives  To analyze the discriminatory power and reliability of dermoscopic criteria used in melanoma detection and compare the diagnostic accuracy of existing algorithms.

Design, Setting, and Participants  This was a retrospective, observational study of 477 lesions (119 melanomas [24.9%] and 358 nevi [75.1%]), which were divided into 12 image sets that consisted of 39 or 40 images per set. A link on the International Dermoscopy Society website from January 1, 2011, through December 31, 2011, directed participants to the study website. Data analysis was performed from June 1, 2013, through May 31, 2015. Participants included physicians, residents, and medical students, and there were no specialty-type or experience-level restrictions. Participants were randomly assigned to evaluate 1 of the 12 image sets.

Main Outcomes and Measures  Associations with melanoma and intraclass correlation coefficients (ICCs) were evaluated for the presence of dermoscopic criteria. Diagnostic accuracy measures were estimated for the following algorithms: the ABCD rule, the Menzies method, the 7-point checklist, the 3-point checklist, chaos and clues, and CASH (color, architecture, symmetry, and homogeneity).

Results  A total of 240 participants registered, and 103 (42.9%) evaluated all images. The 110 participants (45.8%) who evaluated fewer than 20 lesions were excluded, resulting in data from 130 participants (54.2%), 121 (93.1%) of whom were regular dermoscopy users. Criteria associated with melanoma included marked architectural disorder (odds ratio [OR], 6.6; 95% CI, 5.6-7.8), pattern asymmetry (OR, 4.9; 95% CI, 4.1-5.8), nonorganized pattern (OR, 3.3; 95% CI, 2.9-3.7), border score of 6 (OR, 3.3; 95% CI, 2.5-4.3), and contour asymmetry (OR, 3.2; 95% CI, 2.7-3.7) (P < .001 for all). Most dermoscopic criteria had poor to fair interobserver agreement. Criteria that reached moderate levels of agreement included comma vessels (ICC, 0.44; 95% CI, 0.40-0.49), absence of vessels (ICC, 0.46; 95% CI, 0.42-0.51), dark brown color (ICC, 0.40; 95% CI, 0.35-0.44), and architectural disorder (ICC, 0.43; 95% CI, 0.39-0.48). The Menzies method had the highest sensitivity for melanoma diagnosis (95.1%) but the lowest specificity (24.8%) compared with any other method (P < .001). The ABCD rule had the highest specificity (59.4%). All methods had similar areas under the receiver operating characteristic curves.

Conclusions and Relevance  Important dermoscopic criteria for melanoma recognition were revalidated by participants with varied experience. Six algorithms tested had similar but modest levels of diagnostic accuracy, and the interobserver agreement of most individual criteria was poor.

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Comparison of the Diagnostic Accuracy of the Dermoscopic Algorithms

Receiver operating characteristic curves for 6 dermoscopic algorithms were evaluated. CASH indicates color, architecture, symmetry, and homogeneity.

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