Faculty Bibliography

Background/UNASSIGNED:Dermoscopy is undoubtedly a useful tool to improve diagnostic accuracy and minimize the number of unnecessary biopsies. However, much of the literature on dermoscopy focuses on findings in lighter-skin phototypes, leaving potential gaps of knowledge regarding its use in skin of color (SoC). As the clinical applications of dermoscopy continue to increase, understanding dermoscopic patterns in SoC is imperative. Objective/UNASSIGNED:This review discusses the literature on dermoscopic findings of neoplasms in SoC, highlighting unique and characteristic dermoscopic features. Methods/UNASSIGNED:A literature review was performed using the PubMed database. Case reports, case series, case-control studies, and systematic reviews were included. Results/UNASSIGNED:A total of 8326 studies were identified based on the selected search terms, and 41 were included in this review based on relevance. Conclusion/UNASSIGNED:There are specific dermoscopic characteristics in SoC for benign nevi, acral lentiginous melanoma, ethnic melanonychia, and dermatofibroma; however, there is a lack of published data about specific features of cutaneous melanoma, subungual melanoma, pigmented basal cell carcinoma, and pigmented squamous cell carcinoma in SoC. Because pigmented basal cell carcinoma, pigmented squamous cell carcinoma, ethnic melanonychia, and acral lentiginous melanoma are diagnosed at later stages in this population, it is important to understand their dermoscopic features. Further descriptive studies are needed to better characterize unique dermoscopic features in neoplasms in SoC.

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: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.

OBJECTIVES/OBJECTIVE:Melanoma is one of the most common malignancies diagnosed during pregnancy. This study examined the impact of pregnancy on management decisions of melanoma patients treated at NYU Langone Health (NYULH). METHODS:We analyzed data for patients who were pregnant at initial or recurrent melanoma diagnosis at NYULH from 2012 to 2019 with prospective protocol-driven follow-up. RESULTS:Of the 900 female patients accrued during this period, 11 women in the childbearing range were pregnant at melanoma diagnosis. Six patients presented with early (stage 0 or I) disease and five with advanced (stage III or IV) melanoma. Women with early stage disease had normal deliveries and minimal changes to their treatment timeline and regimen. However, patients with more advanced stage disease opted for either termination of the pregnancy or early delivery and altered treatment timelines because of pregnancy. CONCLUSION/CONCLUSIONS:Both melanoma stage and gestational age at diagnosis contribute to the differences in the therapeutic management of melanoma in pregnant women. Given the complexity and variety of each case of melanoma during pregnancy, informed discussion between patients and physicians allows for individualized treatment plans that address each patient's unique situation.

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.

Importance/UNASSIGNED:Use of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care. Objective/UNASSIGNED:To develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies. Evidence Review/UNASSIGNED:The MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed. Findings/UNASSIGNED:The MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility. Conclusions and Relevance/UNASSIGNED:More evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.