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Summary

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

The early diagnosis and excision of cutaneous melanoma is essential for an improved prognosis of the disease. Besides the investigation of pigmented lesions with the unaided eye and conventional dermatoscopy, long-term sequential digital dermatoscopy has been shown to improve the sensitivity of melanoma detection, especially in high-risk patients. In addition to the static clinical and dermatoscopic assessment, the sequential digital dermatoscopy strategy helps to detect changes over time. This review summarizes the latest developments in the field of sequential digital dermatoscopy, describes current strategies for the selection of patients and lesions to monitor, and suggests objective criteria that should lead to an excisional biopsy.


Early detection of cutaneous melanoma by sequential digital dermatoscopy

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

The prognosis of cutaneous melanoma, an aggressive and potentially life-shortening melanocytic tumor, primarily depends on early recognition and prompt excision of the tumor. A smaller tumor thickness (Breslow depth) at excision is associated with a better prognosis [1]. Two meta-analyses have demonstrated that dermatoscopy (synonym: epiluminescence microscopy) can significantly improve the sensitivity for recognition of cutaneous melanomas in comparison to examination with the naked eye [2, 3]. Melanoma-associated dermatoscopic features were first described in the pattern analysis [4], later expanded by additional criteria and summarized in numerous diagnostic algorithms (e.g. 7-point checklist) [5, 6].

Occasionally cutaneous melanoma can lack characteristic features, especially in very early or very advanced stages [7], so that the diagnosis is made more difficult and additional information appears desirable for assessment. Sequential digital dermatoscopy (SDD) by imaging in defined time intervals provides information on the dynamic changes of pigmented lesions. Certain morphologic alterations, such as asymmetric growth, already point to the presence of an initial cutaneous melanoma, even though further melanoma-typical dermatoscopic or clinical criteria are not yet fulfilled [8-10].

It is sensible to differentiate between two strategies of sequential digital dermatoscopy. Short-term follow-up involves one-time control of an individual lesion with higher-grade atypia after maximally three months; an excision should be performed in the event of any dynamic alterations [11, 12]. Long-term follow-up serves to optimize monitoring of patients at risk [13-15]. Here longer examinations intervals of up to 12 months are employed and a larger number of atypical nevi are included in the observation. Optimally, sequential digital dermatoscopy of patients at high risk is supplemented by total body photography, that means overview images of all body regions, to detect newly developed pigmented lesion [9, 16].

Risk factors for the development of melanoma identified in epidemiologic studies are usually easy to either ascertain or to recognize. These include as significant independent risk factors a positive patient or family history of melanoma, the number of typical and atypical nevi, the skin type according to Fitzpatrick, a high density of lentigines, eye and hair color, intermittent UV exposure and the presence of non-melanoma skin cancer [17-19]. Particularly patients with FAMMM syndrome (familial atypical multiple mole melanoma syndrome) have a significantly increased risk of developing melanoma, often already at an early age [20].

Systematic selection of patients for SDD

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

In comparison to conventional dermatoscopy, sequential digital dermatoscopy requires more time and personnel. In order to achieve an acceptable cost-benefit ratio, patient groups with an increased risk of melanoma should be selected systematically for sequential digital dermatoscopy [14].

In routine clinical practice, a simplified scheme for risk classification includes the patient and family history of cutaneous melanomas and differentiates according to phenotype between patients with multiple typical nevi and patients with multiple atypical nevi (atypical mole syndrome, AMS) (Figure 1) [9]. In an earlier study on pigmented lesions with dynamic alterations in the course of time, the relationship of excised cutaneous melanomas to benign nevi was 1: 79 for patients with multiple typical nevi [14]. In this patient group thus many benign lesions were removed due to dynamic alterations in order to diagnose one cutaneous melanoma. In the patient group with multiple atypical nevi, the ratio was already distinctly more favorable with 1: 15, and for patients with FAMMM syndrome even 1: 4. These numbers indicate that dynamic alterations of atypical pigmented lesions in patients with a high to very high risk of melanoma more often point to the presence of a cutaneous melanoma than in the patient groups with a lower risk of melanoma.

image

Figure 1. Lower aspect of back of a patient with multiple, in part atypical nevi.

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Regular control examinations with sequential digital dermatoscopy thus appear useful particularly for patients with multiple atypical nevi and patients with FAMMM syndrome. Further even patients with multiple typical nevi and a melanoma in the patient and/or family history profit from the increased time and effort of sequential digital dermatoscopy [14]. In the same study, melanomas could be diagnosed earlier with sequential digital dermatoscopy than with the combination of examination with the naked eye and conventional dermatoscopy (mean Breslow depth 0.41 mm vs. 0.62 mm; p = 0.04) [14]. In contrast, studies from patients without an increased risk of melanoma were unable to demonstrate benefits from dermatoscopic follow-up of pigmented lesions; many benign pigmented lesions were excised, while no melanomas were identified [21, 22].

Selection of pigmented lesions for SDD

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

In addition to a systematic selection of patients, a careful selection of those pigmented lesions to be documented is required for successful sequential digital dermatoscopy. The selection should first be made after thorough clinical and dermatoscopic examination of the entire skin. Here it is sensible for a first short observation interval (3-month interval) to select those pigmented nevi that demonstrate either macroscopic signs of atypia (asymmetric form, inhomogeneous color or pigment intensity, irregular borders) and/or dermatoscopic signs of atypia (prominent pigment net, a make-up of multiple components, focal eccentric hyper- or hypopigmentation) (Figure 2a–c). These atypia criteria have not yet been definitively defined and thus are subject to a certain subjective and examiner-dependent assessment.

image

Figure 2. Selection of lesions for follow-up by dermatoscopic criteria. Four melanocytic lesions were selected for sequential digital dermatoscopy because of their dermatoscopic atypia. Irregularly distributed homogenous-reticular pattern (a), Focal hyper- and hypopigmentation within a homogenous reticular pattern (b), Homogenous globular pattern with eccentric hyperpigmentation (c), Prominent reticular pattern with centrally located and irregularly demarcated hypopigmentation (d). All lesions showed characteristics of benign nevi during follow-up.

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Further, it is sensible to document pigmented nevi in poorly accessible locations, as the patient can not observe them himself or overlook them. In addition, follow-up must not replace early excision of lesions highly suspicious for melanomas, as this would result in a well-documented delay of the diagnosis.

In patients with an increased risk of melanoma, the nevi which later develop into melanomas often do not yet differ from the rest of the atypical but benign nevi. For this reason a strategy which documents as many flat lesions as possible also appears sensible for follow-up.

Criteria for well-founded decisions for excision

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

A combination of history, clinical examination and sequential digital dermatoscopy proved to be particularly effective in the diagnosis of initial melanomas [9]. The comparison of (digital) overview images with the current findings improved the recognition of newly developed melanomas on formerly normal skin here [16].

That not every documented dynamic alteration in sequential dermatoscopy is associated with the presence of a malignant melanoma, was shown in a study in which pigmented lesions with any alteration in patients with dysplastic nevus syndrome were excised [15]. The ratio of malignant melanoma to benign pigmented nevi in this situation was only 1: 47. In order to increase the effectiveness of this method further, it is therefore important to know what dynamic alterations in pigmented nevi are often associated with malignancy. More than a decade ago, Kittler et al. had already found qualitative differences between dynamic alterations of benign nevi and melanomas [23]. In their study melanomas (n = 8) often demonstrated focal growth in association with changes of the form and the lesional architecture, while most benign nevi showed symmetric growth often with a rim of brown globules at the periphery. In a recently published retrospective study, these results could be confirmed and expanded in a larger series of excised lesions with dynamic alterations during the course (n = 675, of these 61 melanomas) with a comprehensive statistical analysis [24]. Thus, asymmetric-multifocal growth, a newly developed architectural alteration (particularly signs of regression), a focal alteration of pigmentation (in- or decrease) as well as an extensive decrease of pigmentation were significantly associated with the diagnosis of melanoma [24]. On the other hand, in this study as well as in the paper by Kittler et al., symmetric growth of the lesion, the appearance of a complete rim of globuli at the periphery and an increase of pigmentation over the entire pigmented nevus was more often associated with benign than with malignant lesions and should thus not regularly lead to excision (Figure 3a–d).

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Figure 3. Dynamic changes detected by sequential digital dermatoscopy after a 12-month interval. Marked enlargement with eccentric hyperpigmentation and sharp demarcation from uninvolved skin. Superficial spreading melanoma, Breslow tumor thickness 0.35 mm (a, b). Symmetrical enlargement with peripheral rim of brown globules, which is characteristic for benign nevi in adolescent patients (c, d).

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Intervals between the examinations

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

The interval between the individual examinations should be adapted to the individual risk profile. In a recent publication the mean time interval between two successive melanomas in patients with FAMMM syndrome was 4.2 months [14]. It therefore appears prudent to schedule follow-up examinations on a short-term basis (e.g. every 3 months) to detect possible newly developed melanomas early. In patients with dysplastic nevus syndrome the mean interval between two melanomas was 20.3 months [14], so that depending on additional risk factors (such as personal or family history of melanoma), an interval between the examinations of 6–12 months can be recommended. The compliance of patients with respect to the utilization of examination appointments can be improved by a first return visit after 3 to 6 months [25]. In patients with many typical nevi without further risk factors, sequential digital dermatoscopy is usually not required. Regular dermatologic whole-body examination with the conventional dermatoscope should be considered. In individual cases, naturally any time a “short-term follow-up” with a maximum 3-month interval can be recommended for individual pigmented nevi [12].

Conclusions

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References

Sequential digital dermatoscopy is a supplemental examination method to improve early recognition of cutaneous melanomas particularly in groups at risk [26]. A systematic approach with careful selection of the patient groups and the pigmented lesions to be documented is decisive for successful performance of sequential digital dermatoscopy, in order to achieve an acceptable ratio between costs, effort and efficiency. The definition of dynamic criteria that regularly are associated with malignancy and thus lead to the decision for excision appears equally important.

References

  1. Top of page
  2. Summary
  3. Early detection of cutaneous melanoma by sequential digital dermatoscopy
  4. Systematic selection of patients for SDD
  5. Selection of pigmented lesions for SDD
  6. Criteria for well-founded decisions for excision
  7. Intervals between the examinations
  8. Conclusions
  9. References
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