0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Study |

Assessment of the Optimal Interval for and Sensitivity of Short-term Sequential Digital Dermoscopy Monitoring for the Diagnosis of Melanoma FREE

Davide Altamura, MD; Michelle Avramidis, BSc; Scott W. Menzies, MBBS, PhD
[+] Author Affiliations

Author Affiliations: Department of Dermatology, University of L’Aquila, L’Aquila, Italy (Dr Altamura); Sydney Melanoma Diagnostic Centre, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, Australia (Ms Avramidis and Dr Menzies); and Faculty of Medicine, University of Sydney, Sydney, Australia (Dr Menzies).


Arch Dermatol. 2008;144(4):502-506. doi:10.1001/archderm.144.4.502.
Text Size: A A A
Published online

Objective  To determine whether 6 weeks could replace 3 months for short-term sequential digital dermoscopy imaging (ST-SDDI) of suspicious melanocytic lesions and determine the proportion of melanomas missed.

Design  Consecutive lesions (n = 2602) undergoing ST-SDDI monitored from 1859 patients were included. Half of the patients underwent 6-week monitoring followed by 3-month monitoring (range, 2.5-4.5 months) if changes were not seen. The remainder underwent 3-month monitoring only. Any change during this time led to excision. Lesions unchanged were then followed up over time.

Setting  A tertiary referral institution.

Main Outcome Measures  The proportion of changed melanomas (sensitivity) and odds ratios (ORs) for melanoma of changed lesions.

Results  Eighty-one melanomas were detected using ST-SDDI (Breslow thickness: median, in situ; maximum, 0.8 mm). Of 39 melanomas detected using ST-SDDI in the 6-week monitored lesions, 27 (69%) were detected at 6 weeks and 12 (31%) at 3 months. The OR for melanoma for a lesion changing at 6 weeks was 19 (95% confidence interval [CI], 10-35), and the overall OR for melanoma for a lesion changing during the short-term monitoring period (6 weeks to 4.5 months) was 47 (95% CI, 23-94). For lesions remaining unchanged at 3 months, 99.2% (1118 of 1127 lesions) were shown to be benign as defined by an unremarkable further follow-up. Seventy-five percent (15 of 20) of the lentigo maligna melanomas, 93% (40 of 43) of other in situ melanomas, and 96% (26 of 27) of the invasive melanomas were detected using ST-SDDI.

Conclusion  Three months remains the standard interval for ST-SDDI, where the sensitivity for the diagnosis of melanoma for changed (non–lentigo maligna) lesions is high but not 100%.

Figures in this Article

Sequential digital dermoscopy imaging (SDDI) involves the capture and assessment of successive dermoscopic images, separated by an interval, of 1 or many melanocytic lesions, allowing detection of change.111 This imaging technique has been shown to allow the detection of melanoma lacking dermoscopic features of melanoma15 and is performed in 2 settings. Long-term monitoring examines nonsuspicious melanocytic lesions during standard surveillance periods (usually 6-12 months) often in the context of patients with multiple atypical nevi. Here, certain significant predictive changes in malignancy have been defined.1,6 In contrast, short-term digital monitoring (usually for 3 months and always <4.5 months) examines suspicious melanocytic lesions based on morphologic features or patient history but usually without any dermoscopic evidence of melanoma. Unlike long-term monitoring, any morphologic change seen with short-term SDDI (ST-SDDI) requires excision of the lesion.1,3

Currently, most of the data on ST-SDDI follows monitoring at a 3-month interval (range, 2.5-4.5 months).1,3,5,10 Here, the specificity for the diagnosis of melanoma is 83%, with only 17% of atypical benign lesions showing change at that interval.3 In the present study, we assess the diagnostic accuracy of SDDI at 6 weeks compared with the standard 3-month interval to test whether 6 weeks could replace 3 months as the standard interval for ST-SDDI.

Because 1 in 6 atypical benign lesions change during short-term monitoring and because some melanomas show changes after 6 days, it has been suggested that the sensitivity for the diagnosis of melanoma at 3-month monitoring would approach 100% (ie, all melanomas will show change at that interval).3 In the present study, by analysis of follow-up of lesions unchanged at the short-term monitoring period, we present the estimated sensitivity of the technique.

All the patients were examined in the tertiary referral center of the Sydney Melanoma Unit (Sydney Melanoma Diagnostic Centre) between April 1, 1998, and May 31, 2007. In this clinic, SDDI was performed on selected patients using the SolarScan system (Polartechnics Ltd, Sydney), which allows precise color calibration between imaging as previously described.3 In general, suspicious melanocytic lesions, usually flat or slightly raised, without overt dermoscopic evidence of melanoma, underwent ST-SDDI in 2 clinical scenarios1,3: (1) lesions with mild atypia defined as symmetrical or, more frequently, near symmetrical in pigmentation pattern and that had a patient history of change and (2) lesions with moderate atypia defined as more asymmetrical with greater architectural disorder sometimes with a single dermoscopic feature of melanoma (as seen in some dysplastic nevi) but without a history of change.

All consecutive lesions undergoing ST-SDDI (<4.5 months) monitored from 1859 patients (median age, 39 years; age range, 1-90 years; 58% female) were included in the study. All the patients gave written consent for their clinical data to be used, and this study was approved by the ethics committee of the Central Sydney Area Health Service. A flowchart of recruited lesions is seen in Figure 1. Approximately half of the lesions underwent 6-week monitoring followed by 3-month (range, 2.5- to 4.5-month) monitoring if morphologic changes were not seen. The remainder of the lesions underwent 3-month monitoring without 6-week SDDI. Any visual change during this time was considered significant enough to warrant excision, except for an increase or decrease in milialike cysts or a uniform increase or decrease in pigmentation consistent with surrounding skin tanning changes.3

Place holder to copy figure label and caption
Figure 1.

Flowchart of monitored lesions. Six of the 9 malignant melanomas (MMs) detected at follow-up greater than 3 months were from the 6-week-imaged lesions. *Lesions were followed up at a median of 3 months (range, 2.5-4.5 months). †Any change leads to the decision to excise the lesion. ‡Significant changes according to the criteria of Kittler et al6 (see the “Methods” section).

Graphic Jump Location

Follow-up data for lesions remaining unchanged at 3 months were recorded using the clinic database records. Three categories of follow-up were recorded that were considered evidence of a benign lesion: (1) 6- to 8-month SDDI from baseline that showed no morphologic change; (2) greater than 8-month SDDI from baseline that showed none of the significant morphologic changes of size, shape, color, evidence of regression, or appearance of known dermoscopic features of melanoma, according to the criteria of Kittler et al6; and (3) a routine skin examination more than 12 months after baseline imaging without detecting melanoma (Figure 1).

6-WEEK VS 3-MONTH MONITORING

A total of 1331 suspicious melanocytic lesions underwent 6-week SDDI. If any morphologic change occurred at that time, excision was performed. If no change occurred, then conventional short-term monitoring at a median of 3 months (range, 2.5-4.5 months) after baseline imaging was performed. At this time, lesions undergoing any morphologic change underwent excision (Figure 1). Of the 39 melanomas detected using the 6-week to 3-month follow-up setting, 27 (69%) were detected at 6 weeks. At the 6-week interval, 96 benign lesions were excised because of change, resulting in a specificity for the diagnosis of melanoma of 93% (on the assumption of 1292 benign lesions in this set). The odds ratio (OR) for melanoma for a lesion changing at 6 weeks was 19 (95% confidence interval [CI], 10-35). Thirty-one percent of the melanomas (n = 12) required 3-month monitoring for detection (ie, changed at 3 months but not at 6 weeks). A further 118 benign lesions were excised because of morphologic change at this time. The OR for melanoma for a lesion changing at 3 months without change at 6 weeks was similar at 18 (95% CI, 7-49). The overall OR for melanoma for a lesion changing during the short-term monitoring period (6 weeks to 4.5 months) was 47 (95% CI, 23-94). Finally, 57% (46 of 81) of the melanomas detected using short-term monitoring had no dermoscopic features of melanoma on either the baseline or follow-up image using the method of Menzies et al.12 Examples of lesions that changed during ST-SDDI are shown in Figure 2 and Figure 3.

Place holder to copy figure label and caption
Figure 2.

A superficial spreading melanoma (0.5-mm Breslow thickness) that changed during short-term sequential digital dermoscopy imaging. A, Baseline image of a 4.5-mm-diameter lesion on the forearm of a 34-year-old woman. B, Six-week follow-up image showing changes, including extension of pigmentation (arrow) and loss of brown globules (inferior to the head of the arrow). Bar = 1 mm.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A lentigo maligna lesion that changed during short-term sequential digital dermoscopy imaging. A, Baseline image of a 7.6-mm-diameter lesion on the cheek of a 61-year-old man. B, Six-week follow-up image showing changes, including extension of pigmentation (arrows), with an increase to 8.2 mm in diameter. Bar = 1 mm.

Graphic Jump Location
FOLLOW-UP OF LESIONS UNCHANGED AT 3-MONTH IMAGING

Of the 2602 lesions monitored during the short-term interval (<4.5 months; median, 3 months, incorporating lesions monitored with and without the 6-week interval), 81 melanoma and 406 benign lesions were excised because of change (Figure 1). To assess whether any melanomas were not identified during the short-term monitoring period (ie, false-negative melanomas remaining unchanged at 3 months), an assessment of the unchanged lesions in routine clinical follow-up was performed. Of the 2115 lesions that remained unchanged at 3 months, 1127 (53%) had significant follow-up records. These had medium-term imaging (6-8 months since baseline), where any change detected resulted in excision; long-term imaging beyond 8 months, where any “significant” morphologic changes as defined by Kittler et al6 resulted in excision; or routine clinical examination using dermoscopy beyond 12 months after baseline imaging (Figure 1). Of those 1127 lesions, 9 false-negative melanomas were detected (8 of 9 were in situ and 1 was invasive [0.3-mm Breslow thickness]). Of these misclassified melanomas, 5 were lentigo maligna. Although there was a decrease in the proportion of correctly detected lentigo maligna at short-term monitoring (sensitivity, 75%) compared with 93% sensitivity for non–lentigo maligna in situ melanoma and 96% sensitivity for invasive melanoma, this was not statistically significant (Table) (with sensitivity values calculated assuming that no melanomas were present in the group lost to follow-up). There was no statistically significant difference between the median Breslow thickness of melanomas detected at ST-SDDI (in situ; range, 0-0.8 mm) compared with those misclassified (in situ; range, 0-0.3 mm) (P = .18, Wilcoxon rank sum test).

Table Graphic Jump LocationTable. Histologic Subtypes of Melanomas Detected or Undetected by Short-term Monitoring

The specificity for the diagnosis of melanoma when excising a lesion for any change during short-term monitoring was 84%, with 406 benign lesions excised from 2512 imaged at baseline. For lesions remaining unchanged at 3 months, 99.2% (1118 of 1127 lesions) were shown to be benign on follow-up. The OR for melanoma for a lesion without change at 3 months was 0.02 (95% CI, 0.01-0.04).

The main aim of this study was to determine whether the interval for assessing suspicious melanocytic lesions using SDDI could be reduced from 3 months to 6 weeks. Because 31% of the melanomas detected during short-term monitoring did not change at 6 weeks and there was no significant difference in median Breslow thickness between melanomas detected at 6 weeks vs 3 months, there seems to be little advantage in reducing the recommended interval. However, when assessing suspicious pigmented macules of the face, the observation that only 75% of lentigo maligna lesions were detected at 3 months suggests the need for an additional long-term monitoring image to be taken before excluding malignancy. We suggest that this imaging occur 6 to 12 months after baseline imaging, but the evidence for this suggested interval lacks formal investigation.

Seven percent of non–lentigo maligna in situ melanomas and 4% of invasive melanomas were not detected using ST-SDDI. Nevertheless, these melanomas remained thin when detected at longer follow-up, with 8 of the 9 remaining in situ and the 1 invasive melanoma having a Breslow thickness of 0.3 mm. The slow vertical growth of these misclassified melanomas was consistent with the slow growth seen by lack of morphologic changes noted during the short-term monitoring period.

The estimates of missed melanomas were calculated on the assumption that there were no melanomas in the group lost to follow-up. For this reason, the sensitivities may be overestimated. However, because all the patients are instructed to return if any change occurs with their monitored lesion and many of the patients lost to follow-up underwent monitoring more than 12 months before the closing date of the study, this assumption seems more appropriate than extrapolating an incidence of missed melanoma in the follow-up group. Furthermore, the estimates of missed melanoma assume that all the lesions subsequently proved to be melanoma on long-term follow-up were melanoma at baseline imaging, which in the case of the non–lentigo maligna melanomas may not be true because in high-risk patients we assume a certain rate of melanoma newly developing within nevi.

This study was not a randomized trial but rather a retrospective analysis of consecutive patients undergoing SDDI at a single institution. Although the same criteria were used in patients undergoing 6-week or 3-month monitoring, a possible limitation exists because of the lack of randomization into the 2 monitoring arms. Another confounder that may occur in sequential digital monitoring is pseudochange due to compression differences or stretching of the skin. Artifactual change due to stretching of the skin is usually easily identified by an increase in diameter of 1 lesion axis with a corresponding shortening of the perpendicular axis.

The safety of SDDI is again underlined in this study. As previously reported in a series of melanomas detected by short- and long-term monitoring,1 all the melanomas in this study were less than 0.8 mm in Breslow thickness, with a median Breslow thickness of in situ melanoma. Suspicious nodular lesions are never monitored using SDDI.

Five studies15 previously published on SDDI show that the technique allows the detection of melanomas that lack dermoscopic evidence of malignancy. In particular, in 1 prospective study2 of melanomas diagnosed by a variety of clinical means, 34% were detected exclusively using the findings of SDDI and were dermoscopically featureless. In the present study, 57% of melanomas detected at short-term monitoring had no dermoscopic features of melanoma. Furthermore, changes detected using SDDI are subtle and would not be detected using routine dermoscopic examination without the aid of an archiving facility that allows comparison of lesions tiled on the computer screen. Finally, the specificity for the diagnosis of melanoma when excising a lesion for any change during short-term monitoring was 84% (ie, 16% of suspicious benign melanocytic lesions changed during short-term monitoring). This reproduced the original findings.3

Correspondence: Scott W. Menzies, MBBS, PhD, Sydney Melanoma Diagnostic Centre, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia 2050 (scott.menzies@email.cs.nsw.gov.au).

Accepted for Publication: December 7, 2007.

Author Contributions: Drs Altamura and Menzies had access to the data collected, and Dr Menzies is responsible for its analysis. Study concept and design: Menzies. Acquisition of data: Altamura, Avramidis, and Menzies. Analysis and interpretation of data: Menzies. Drafting of the manuscript: Menzies. Critical revision of the manuscript for important intellectual content: Altamura and Avramidis. Statistical analysis: Menzies. Obtained funding: Menzies. Administrative, technical, and material support: Menzies. Study supervision: Menzies.

Financial Disclosure: Dr Menzies was a paid consultant of Polartechnics Ltd, the manufacturer of the digital dermoscopy monitoring device used in the study.

Kittler  HGuitera  PRiedl  E  et al.  Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol 2006;142 (9) 1113- 1119
PubMed
Haenssle  HAKrueger  UVente  C  et al.  Results from an observational trial: digital epiluminescence microscopy follow-up of atypical nevi increases the sensitivity and the chance of success of conventional dermoscopy in detecting melanoma. J Invest Dermatol 2006;126 (5) 980- 985
PubMed
Menzies  SWGutenev  AAvramidis  MBatrac  AMcCarthy  WH Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001;137 (12) 1583- 1589
PubMed
Robinson  JKNickoloff  BJ Digital epiluminescence microscopy monitoring of high-risk patients. Arch Dermatol 2004;140 (1) 49- 56
PubMed
Skvara  HTeban  LFiebiger  MBinder  MKittler  H Limitations of dermoscopy in the recognition of melanoma. Arch Dermatol 2005;141 (2) 155- 160
PubMed
Kittler  HPehamberger  HWolff  KBinder  M Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000;43 (3) 467- 476
PubMed
Stolz  WSchiffner  RPillet  L  et al.  Improvement of monitoring of melanocytic skin lesions with the use of a computerized acquisition and surveillance unit with a skin surface microscopic television camera. J Am Acad Dermatol 1996;35 (2, pt 1) 202- 207
PubMed
Braun  RPLemonnier  EGuillod  J  et al.  Two types of pattern modification detected on the follow-up of benign melanocytic skin lesions by digitized epiluminescence microscopy. Melanoma Res 1998;8 (5) 431- 437
PubMed
Bauer  JBlum  AStrohhacker  UGarbe  C Surveillance of patients at high risk for cutaneous malignant melanoma using digital dermoscopy. Br J Dermatol 2005;152 (1) 87- 92
PubMed
Malvehy  JPuig  S Follow-up of melanocytic skin lesions with digital total-body photography and digital dermoscopy: a two-step method. Clin Dermatol 2002;20 (3) 297- 304
PubMed
Schiffner  RSchiffner-Rohe  JLandthaler  MStolz  W Long-term dermoscopic follow-up of melanocytic naevi: clinical outcome and patient compliance. Br J Dermatol 2003;149 (1) 79- 86
PubMed
Menzies  SWIngvar  CCrotty  KAMcCarthy  WH Frequency and morphologic characteristics of invasive melanomas lacking specific surface microscopic features. Arch Dermatol 1996;132 (10) 1178- 1182
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Flowchart of monitored lesions. Six of the 9 malignant melanomas (MMs) detected at follow-up greater than 3 months were from the 6-week-imaged lesions. *Lesions were followed up at a median of 3 months (range, 2.5-4.5 months). †Any change leads to the decision to excise the lesion. ‡Significant changes according to the criteria of Kittler et al6 (see the “Methods” section).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A superficial spreading melanoma (0.5-mm Breslow thickness) that changed during short-term sequential digital dermoscopy imaging. A, Baseline image of a 4.5-mm-diameter lesion on the forearm of a 34-year-old woman. B, Six-week follow-up image showing changes, including extension of pigmentation (arrow) and loss of brown globules (inferior to the head of the arrow). Bar = 1 mm.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A lentigo maligna lesion that changed during short-term sequential digital dermoscopy imaging. A, Baseline image of a 7.6-mm-diameter lesion on the cheek of a 61-year-old man. B, Six-week follow-up image showing changes, including extension of pigmentation (arrows), with an increase to 8.2 mm in diameter. Bar = 1 mm.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Histologic Subtypes of Melanomas Detected or Undetected by Short-term Monitoring

References

Kittler  HGuitera  PRiedl  E  et al.  Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol 2006;142 (9) 1113- 1119
PubMed
Haenssle  HAKrueger  UVente  C  et al.  Results from an observational trial: digital epiluminescence microscopy follow-up of atypical nevi increases the sensitivity and the chance of success of conventional dermoscopy in detecting melanoma. J Invest Dermatol 2006;126 (5) 980- 985
PubMed
Menzies  SWGutenev  AAvramidis  MBatrac  AMcCarthy  WH Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001;137 (12) 1583- 1589
PubMed
Robinson  JKNickoloff  BJ Digital epiluminescence microscopy monitoring of high-risk patients. Arch Dermatol 2004;140 (1) 49- 56
PubMed
Skvara  HTeban  LFiebiger  MBinder  MKittler  H Limitations of dermoscopy in the recognition of melanoma. Arch Dermatol 2005;141 (2) 155- 160
PubMed
Kittler  HPehamberger  HWolff  KBinder  M Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000;43 (3) 467- 476
PubMed
Stolz  WSchiffner  RPillet  L  et al.  Improvement of monitoring of melanocytic skin lesions with the use of a computerized acquisition and surveillance unit with a skin surface microscopic television camera. J Am Acad Dermatol 1996;35 (2, pt 1) 202- 207
PubMed
Braun  RPLemonnier  EGuillod  J  et al.  Two types of pattern modification detected on the follow-up of benign melanocytic skin lesions by digitized epiluminescence microscopy. Melanoma Res 1998;8 (5) 431- 437
PubMed
Bauer  JBlum  AStrohhacker  UGarbe  C Surveillance of patients at high risk for cutaneous malignant melanoma using digital dermoscopy. Br J Dermatol 2005;152 (1) 87- 92
PubMed
Malvehy  JPuig  S Follow-up of melanocytic skin lesions with digital total-body photography and digital dermoscopy: a two-step method. Clin Dermatol 2002;20 (3) 297- 304
PubMed
Schiffner  RSchiffner-Rohe  JLandthaler  MStolz  W Long-term dermoscopic follow-up of melanocytic naevi: clinical outcome and patient compliance. Br J Dermatol 2003;149 (1) 79- 86
PubMed
Menzies  SWIngvar  CCrotty  KAMcCarthy  WH Frequency and morphologic characteristics of invasive melanomas lacking specific surface microscopic features. Arch Dermatol 1996;132 (10) 1178- 1182
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Melanoma

The Rational Clinical Examination
Make the Diagnosis: Melanoma