Faculty Bibliography

BACKGROUND:MoleMap NZ is a novel New Zealand based store-and-forward telemedicine service to detect melanoma. It utilizes expert review of total body photography and close-up and dermoscopic images of skin lesions suspicious for malignancy. OBJECTIVE:The purpose of this study was to assess the effectiveness of MoleMap NZ as a melanoma early detection program. METHODS:We conducted a review of 2,108 melanocytic lesions recommended for biopsy/excision by MoleMap NZ dermoscopists from January 2015-December 2016. RESULTS:Pathologic diagnoses were available for 1,571 lesions. Of these, 1,303 (83%) lesions were benign and 260 (17%) lesions were diagnosed as melanoma, for a melanoma-specific benign-to-malignant ratio of 5.0 to 1. The number-needed-to-biopsy one melanoma was 6. Among melanomas with available tumor thickness data (n=137), 92% were <0.8mm (range: in situ - 3.1mm), with in-situ melanomas comprising 74%. LIMITATIONS/CONCLUSIONS:Only lesions recommended for excision were analyzed. Pathology results were available for 75% of these cases. Tumor thickness data was available for 53% of melanomas diagnosed. CONCLUSION/CONCLUSIONS:This real-world study of MoleMap NZ, a community-based teledermoscopy program, suggests that it has the potential to increase patients' access to specialist expertise via telemedicine. Additional studies are needed to more accurately define its efficacy.

Nevisense is an FDA-cleared device to aid in diagnosing melanoma. Using a non-invasive probe, the device measures electrical impedance spectroscopy (EIS) of target skin lesions. While EIS has demonstrated high sensitivity in diagnosing melanoma, its impact on a clinician's diagnostic confidence remains unknown. We conducted a pilot study evaluating whether the addition of EIS scores to clinical and dermoscopic images increases diagnostic confidence, accuracy, sensitivity, and specificity for students and dermatologists when evaluating lesions clinically suspicious for melanoma. Three pigmented lesions specialists and three 4^th year medical students completed an online survey to evaluate 34 melanocytic lesions suspicious for melanoma. For each lesion, participants provided their diagnosis, biopsy recommendation, and confidence in diagnosing a lesion as benign or malignant based on history and clinical and dermoscopic images, and again after receiving an EIS score. Addition of EIS scores increased mean biopsy sensitivity for melanoma/severe dysplastic nevi (DN) from 70% to 84% (p =.014) and mean diagnostic accuracy from 74% to 86% (p =.005). Mean diagnostic confidence increased for 29/34 lesions, of which 26 were accurately diagnosed by >=4 evaluators. Increases in diagnostic confidence were significant for common melanocytic nevi, DN, and melanoma, for both students and dermatologists (all p <.05). Use of EIS may increase clinicians' confidence to provide greater reassurance regarding dermoscopically equivocal lesions such as DN. EIS thus has the potential to help clinicians better alleviate patients' anxieties during skin exams. EIS may also improve management of melanocytic lesions suspicious for melanoma among novice and expert diagnosticians, though further investigation is needed to determine if these findings translate to clinical settings. NB: All authors except for Ms. Fried are team members for a separate study utilizing a Nevisense device, loaned to NYU by Scibase.
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Importance/UNASSIGNED:Dermoscopy education in US dermatology residency programs varies widely, and there is currently no existing expert consensus identifying what is most important for resident physicians to know. Objectives/UNASSIGNED:To identify consensus-based learning constructs representing an appropriate foundational proficiency in dermoscopic image interpretation for dermatology resident physicians, including dermoscopic diagnoses, associated features, and representative teaching images. Defining these foundational proficiency learning constructs will facilitate further skill development in dermoscopic image interpretation to help residents achieve clinical proficiency. Design, Setting, and Participants/UNASSIGNED:A 2-phase modified Delphi surveying technique was used to identify resident learning constructs in 3 sequential sets of surveys-diagnoses, features, and images. Expert panelists were recruited through an email distributed to the 32 members of the Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group. Twenty-six (81%) opted to participate. Surveys were distributed using RedCAP software. Main Outcomes and Measures/UNASSIGNED:Consensus on diagnoses, associated dermoscopic features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for US dermatology resident physicians. Results/UNASSIGNED:Twenty-six pigmented lesion and dermoscopy specialists completed 8 rounds of surveys, with 100% (26/26) response rate in all rounds. A final list of 32 diagnoses and 116 associated dermoscopic features was generated. Three hundred seventy-eight representative teaching images reached consensus with panelists. Conclusions and Relevance/UNASSIGNED:Consensus achieved in this modified Delphi process identified common dermoscopic diagnoses, associated features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for dermatology residency training. This list of validated objectives provides a consensus-based foundation of key learning points in dermoscopy to help resident physicians achieve clinical proficiency in dermoscopic image interpretation.

BACKGROUND:Acral lentiginous melanoma is associated with worse survival than other subtypes of melanoma. Understanding prognostic factors for survival and recurrence can help better inform follow-up care. OBJECTIVES/OBJECTIVE:To analyze the clinicopathologic features, melanoma-specific survival, and recurrence-free survival by substage in a large, multi-institutional cohort of primary acral lentiginous melanoma patients. METHODS:Retrospective review of the United States Melanoma Consortium database, a multi-center prospectively collected database of acral lentiginous melanoma patients treated between January 2000 and December 2017. RESULTS:= .001) were also prognostic factors for recurrence-free survival. CONCLUSION/CONCLUSIONS:In this cohort of patients, acral lentiginous melanoma was associated with poor outcomes even in early stage disease, consistent with prior reports. Stage IIB and IIC disease were associated with particularly low melanoma-specific and recurrence-free survival. This suggests that studies investigating adjuvant therapies in stage II patients may be especially valuable in acral lentiginous melanoma patients.

The growth of molecular technologies analyzing skin cells and inherited genetic variations has the potential to address current gaps in both diagnostic accuracy and prognostication in melanoma patients or in individuals at risk for developing melanoma. In part II of this continuing medical education article, novel molecular technologies are reviewed. These have been developed as adjunct tools for melanoma management and include the Pigmented Lesion Assay (PLA), myPath Melanoma, and DecisionDx-Melanoma tests, and genetic testing in patients with a strong familial melanoma history. These tests are commercially available and marketed as ancillary tools for clinical decision-making, diagnosis, and prognosis. Here we review fundamental principles behind each test, discuss peer-reviewed literature assessing their performance, and highlight the utility and limitations of each assay. The goal of this article is to provide a comprehensive, evidence-based foundation for clinicians regarding management of patients with difficult pigmented lesions.

Managing the balance between accurately identifying early stage melanomas while avoiding obtaining biopsy specimens of benign lesions (ie, overbiopsy) is the major challenge of melanoma detection. Decision making can be especially difficult in patients with extensive atypical nevi. Recognizing that the primary screening modality for melanoma is subjective examination, studies have shown a tendency toward overbiopsy. Even low-risk routine surgical procedures are associated with morbidity, mounting health care costs, and patient anxiety. Recent advancements in noninvasive diagnostic modalities have helped improve diagnostic accuracy, especially when managing melanocytic lesions of uncertain diagnosis. Breakthroughs in artificial intelligence have also shown exciting potential in changing the landscape of melanoma detection. In the first article in this continuing medical education series, we review novel diagnostic technologies, such as automated 2- and 3-dimensional total body imaging with sequential digital dermoscopic imaging, reflectance confocal microscopy, and electrical impedance spectroscopy, and we explore the logistics and implications of potentially integrating artificial intelligence into existing melanoma management paradigms.

A 45-year-old woman with cirrhosis secondary to alcohol abuse was transferred from an outside hospital for management of a painful cutaneous eruption, progressively worsening over 2 weeks. On examination, the patient was a middle-aged white woman lying in bed in no acute distress, with jaundice and a protuberant abdomen consistent with ascites. The patient was afebrile (98.2°F), heart rate of 79 beats per minute, blood pressure of 105/61 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 93% on room air. She had multiple large stellate lesions of retiform purpura with central hemorrhagic necrosis on both thighs, with surrounding induration (Figures 1 and 2). These purpuric plaques and perilesional skin were exquisitely painful to palpation.