Faculty Bibliography

Purpose: The use of a posterior augmented glenoid to correct posterior wear, subluxation and retroversion remains controversial. The purpose of this study is to compare the clinical and radiographic outcomes of patients with significant posterior glenoid wear treated with a posterior augmented glenoid and compare them to age/gender/follow-up matched patients without glenoid wear treated with a non-augmented pegged glenoid in anatomic total shoulder arthroplasty (aTSA). Method(s): 182 patients undergoing primary aTSA with 2 year minimum follow-up (mean 42 months)were reviewed. 91 patients (mean age = 66 yrs; 37F/54M)received a posterior augmented pegged glenoid and 91 age/gender/follow-up matched patients received a non-augmented pegged glenoid. Patient data was retrospectively reviewed from a multi-institutional WIRB approved registry. Each patient was evaluated preoperatively and at latest follow-up using SST, UCLA, ASES, Constant, and SPADI scoring metrics; active abduction, forward flexion, and internal/external rotation were measured. Radiolucent glenoid line assessment was performed from radiographs at latest follow up. A Student's two tailed unpaired t-test (P <.05)quantified differences. Result(s): Each cohort demonstrated significant improvements in pain and function following primary aTSA. At latest follow-up, augmented glenoids were generally better than non-augmented glenoids; however, few differences were noted in pre-to-postoperative improvement between augmented and non-augmented glenoids. Augmented glenoids were associated with significantly more improvement in active abduction, forward flexion, and external rotation as compared to non-augmented glenoids. The overall complication rate was 6.6%, where augmented patients had 1 aseptic glenoid loosening compared to 3 cases in the non-augmented group. Radiographic data was available for 70% of the patients. There were no significant differences in the rate of glenoid radiolucent lines (35% augmented, 40% non-augmented)or the average line grade (0.68 augmented, 0.86 non-augmented)between the two cohorts. There were no differences in humeral radiolucent line rates between the two groups. Discussion(s): At a mean follow-up of 3.5 years, few clinically relevant differences were observed between the augmented and non-augmented cohorts, despite the augment cohort being disadvantaged by posterior glenoid wear. This is likely due to the correction of the retroversion and posterior subluxation, with improved tensioning of the rotator cuff. There were no patients in which the humeral head re-subluxated posteriorly. Complication rates and radiographic outcomes were similar between the two groups. Posterior augmented glenoids are a viable option for the posteriorly worn osteoarthritic glenoid; however, longer follow-up is necessary to determine how these early results hold up over time.

Dysplastic nevi have been a subject of much debate since their original description in 1978. Although some question the biological potential of dysplastic nevi themselves, several studies have shown that their presence confers substantial risk for melanoma. In addition to predisposing patients to melanoma, dysplastic nevi have been shown to harbor genetic mutations, indicating their position on a continuum between banal nevi and melanomas. Dysplastic nevi are also clinically relevant as mimickers of melanoma, and can be challenging diagnostically. This article reviews the history, epidemiology, biology and genetics, clinical features, histopathologic features, and management guidelines for patients with these lesions.

Early detection of malignant melanoma remains the key factor in lowering mortality from this cancer. Recognizing the importance of this issue 25 years ago, our group at New York University published in CA: A Cancer Journal for Clinicians the mnemonic 'ABCD' to facilitate the early diagnosis of melanoma. Studies have demonstrated the usefulness of this paradigm in enhancing early melanoma diagnosis as a part of clinical examinations, mass screenings, and public education programs. Approaches to melanoma diagnosis have dynamically evolved during the ensuing quarter century. In the 1990s, dermoscopy enabled the recognition of new subsurface features to differentiate between malignant and benign pigmented lesions. During the last decade, new computer-based technologies have improved diagnostic sensitivity and specificity and may result in optimizing lesion selection for biopsy and pathology review. Despite all of the advances in melanoma diagnosis, timely recognition, detection, and rapid treatment of melanoma remain critical. Although pathologic examination remains the gold standard for diagnosis, this cancer has the potential to be diagnosed through noninvasive approaches because of its cutaneous location. From the development of the ABCDs through current attempts that use complex computer algorithms and genetic markers, a clinician's ability to detect melanoma in its earliest form has been augmented. However, a 'good clinical eye' is still fundamental to selecting the lesions for evaluation among the sea of those that are prevalent. As current approaches are refined and new techniques are developed, the improved ability to diagnose this cancer will hopefully enhance reaching the goal of reducing melanoma mortality

Dysplastic nevi have become an increasing focus clinically, with evidence that they are associated with a higher risk of developing melanoma. However, there still is contention regarding the significance of dysplastic nevi. This contribution provides an overview of the history, epidemiology, genetics, clinical and histologic features, and procedures for clinical management of dysplastic nevi. Since dysplastic nevi were described originally in 1978, a great deal of research has examined the epidemiology of these lesions and the genetic factors related to the development of dysplastic nevi. However, there is disagreement regarding the clinical management of dysplastic nevi and the histologic definition of dysplastic nevi. Current recommendations include preventative measures, such as sun protection and careful surveillance and biopsies of suspicious lesions as needed. The advent of new technologies, such as computer-vision systems, have the potential to significantly change treatment of dysplastic nevi in the future

OBJECTIVE: To evaluate the performance of dermoscopists in diagnosing small pigmented skin lesions (diameter </= 6 mm) compared with an automatic multispectral computer-vision system. DESIGN: Blinded comparison study. SETTING: Dermatologic hospital-based clinics and private practice offices. Patients From a computerized skin imaging database of 990 small (</= 6-mm) pigmented skin lesions, all 49 melanomas from 49 patients were included in this study. Fifty randomly selected nonmelanomas from 46 patients served as a control. MAIN OUTCOME MEASURES: Ten dermoscopists independently examined dermoscopic images of 99 pigmented skin lesions and decided whether they identified the lesions as melanoma and whether they would recommend biopsy to rule out melanoma. Diagnostic and biopsy sensitivity and specificity were computed and then compared with the results of the computer-vision system. RESULTS: Dermoscopists were able to correctly identify small melanomas with an average diagnostic sensitivity of 39% and a specificity of 82% and recommended small melanomas for biopsy with a sensitivity of 71% and specificity of 49%, with only fair interobserver agreement (kappa = 0.31 for diagnosis and 0.34 for biopsy). In comparison, in recommending biopsy to rule out melanoma, the computer-vision system achieved 98% sensitivity and 44% specificity. CONCLUSIONS: Differentiation of small melanomas from small benign pigmented lesions challenges even expert physicians. Computer-vision systems can facilitate early detection of small melanomas and may limit the number of biopsies to rule out melanoma performed on benign lesions

OBJECTIVE: To determine the utility of the current diameter criterion of larger than 6 mm of the ABCDE acronym for the early diagnosis of cutaneous melanoma. DESIGN: Cohort study. SETTING: Dermatology hospital-based clinics and community practice offices. Patients A total of 1323 patients undergoing skin biopsies of 1657 pigmented lesions suggestive of melanoma. MAIN OUTCOME MEASURE: The maximum lesion dimension (diameter) of each skin lesion was calculated before biopsy using a novel computerized skin imaging system. RESULTS: Of 1657 biopsied lesions, 853 (51.5%) were 6 mm or smaller in diameter. Invasive melanomas were diagnosed in 13 of 853 lesions (1.5%) that were 6 mm or smaller in diameter and in 41 of 804 lesions (5.1%) that were larger than 6 mm in diameter. In situ melanomas were diagnosed in 22 of 853 lesions (2.6%) that were 6 mm or smaller in diameter and in 62 of 804 lesions (7.7%) that were larger than 6 mm in diameter. Conclusion The diameter guideline of larger than 6 mm provides a useful parameter for physicians and should continue to be used in combination with the A, B, C, and E criteria previously established in the selection of atypical lesions for skin biopsy

CONTEXT: The incidence of cutaneous melanoma has increased over the past several decades, making its early diagnosis a continuing public health priority. The ABCD (Asymmetry, Border irregularity, Color variegation, Diameter >6 mm) acronym for the appraisal of cutaneous pigmented lesions was devised in 1985 and has been widely adopted but requires reexamination in light of recent data regarding the existence of small-diameter (< or =6 mm) melanomas. EVIDENCE ACQUISITION: Cochrane Library and PubMed searches for the period 1980-2004 were conducted using search terms ABCD and melanoma and small-diameter melanoma. Bibliographies of retrieved articles were also used to identify additional relevant information. EVIDENCE SYNTHESIS: Available data do not support the utility of lowering the diameter criterion of ABCD from the current greater than 6 mm guideline. However, the data support expansion to ABCDE to emphasize the significance of evolving pigmented lesions in the natural history of melanoma. Physicians and patients with nevi should be attentive to changes (evolving) of size, shape, symptoms (itching, tenderness), surface (especially bleeding), and shades of color. CONCLUSIONS: The ABCD criteria for the gross inspection of pigmented skin lesions and early diagnosis of cutaneous melanoma should be expanded to ABCDE (to include 'evolving'). No change to the existing diameter criterion is required at this time