Melanoma

To the Editor:

An 81-year-old man presented with a nodular polypoid lesion that developed on a flat lesion on the back of 2 years’ duration. The lesion grew progressively over the course of 3 months prior to presentation. The patient had a history of melanoma in situ on the forehead that was treated with conventional surgery with clear surgical margins 6 years prior to the current presentation.

On physical examination the patient had a 4×2-cm ulcerated polypoid lesion on the back. The lesion was pink with a pigmented base. Additionally, 2 pink papules with superficial telangiectases were observed around the main lesion (Figure 1).

The gross section showed an exophytic tumor largely growing above the skin surface (Figure 2). Histopathologic analysis revealed an ulcerated lesion consisting of confluent nest and sheets of epithelioid and spindle atypical cells with numerous mitotic figures and necrotic foci (Figure 3). The thickness of the lesion was 2200 µm, and the mitotic count was 28 mitoses/mm². There also was peritumoral vascular invasion and satellite metastasis within the perilesional hypodermis measuring 0.4 mm. Immunohistochemistry staining for S-100, human melanoma black 45 (HMB-45)(Figure 4), and Melan-A was positive in neoplastic cells.

The dissemination study revealed multiple mediastinal and axillary lymphadenopathies and lesions with metastatic appearance in the brain, liver, pancreas, and muscle, together with peritoneal carcinomatosis. The patient was lost to follow-up and did not follow coadjuvant therapy with interferon alfa.

Polypoid melanoma initially was described as a type of melanoma characterized by an exophytic growth in which most of the tumor is located on the cutaneous surface, together with ulceration.¹ It usually occurs in patients aged 20 to 39 years,² and the reported incidence ranges from 1.9% to 43.3%.¹ It more commonly affects mucosae, including the upper respiratory tract, esophagus, and vagina. Polypoid melanoma has a rapid progression and a poor prognosis.³ Polypoid melanoma involving the skin primarily affects the back and has a 5-year survival rate of 32% to 42%.⁴ Poor prognosis has been attributed to the high risk for vascular embolization under the lesion.⁵ Histologically, there is marked cell atypia with nuclear and cellular pleomorphism and a high mitotic count. The tumor rarely involves the reticular dermis.^1,2

Polypoid melanomas are rare; however, reported frequency rates cover a wide range. These frequency rates may be due to the definition of polypoid melanoma used by the pathologist issuing the report. One of the most accepted definitions at present is a pigmented macule that progresses in months with a rapid vertical growth, invading the epidermis and the papillary dermis.² The differential diagnosis includes pyogenic granuloma, squamous cell carcinoma, basal cell carcinoma, soft tissue sarcomas, and hemangioma.

Although our patient had a history of melanoma and the polypoid lesion developed from a flat lesion, he was late to seek medical care. The diagnosis of melanoma is made on increasingly smaller lesions with better prognosis, but there still are reports of larger melanomas. This case highlights the role dermatologists serve in the education of patients on their diagnoses and risk factors so that we may be able to diagnose non–life-threatening small lesions. It is important to remember this morphologic variety of melanoma and highlight its rapid progression and poor prognosis.

To the Editor:

An 81-year-old man presented with a nodular polypoid lesion that developed on a flat lesion on the back of 2 years’ duration. The lesion grew progressively over the course of 3 months prior to presentation. The patient had a history of melanoma in situ on the forehead that was treated with conventional surgery with clear surgical margins 6 years prior to the current presentation.

On physical examination the patient had a 4×2-cm ulcerated polypoid lesion on the back. The lesion was pink with a pigmented base. Additionally, 2 pink papules with superficial telangiectases were observed around the main lesion (Figure 1).

The gross section showed an exophytic tumor largely growing above the skin surface (Figure 2). Histopathologic analysis revealed an ulcerated lesion consisting of confluent nest and sheets of epithelioid and spindle atypical cells with numerous mitotic figures and necrotic foci (Figure 3). The thickness of the lesion was 2200 µm, and the mitotic count was 28 mitoses/mm². There also was peritumoral vascular invasion and satellite metastasis within the perilesional hypodermis measuring 0.4 mm. Immunohistochemistry staining for S-100, human melanoma black 45 (HMB-45)(Figure 4), and Melan-A was positive in neoplastic cells.

The dissemination study revealed multiple mediastinal and axillary lymphadenopathies and lesions with metastatic appearance in the brain, liver, pancreas, and muscle, together with peritoneal carcinomatosis. The patient was lost to follow-up and did not follow coadjuvant therapy with interferon alfa.

Polypoid melanoma initially was described as a type of melanoma characterized by an exophytic growth in which most of the tumor is located on the cutaneous surface, together with ulceration.¹ It usually occurs in patients aged 20 to 39 years,² and the reported incidence ranges from 1.9% to 43.3%.¹ It more commonly affects mucosae, including the upper respiratory tract, esophagus, and vagina. Polypoid melanoma has a rapid progression and a poor prognosis.³ Polypoid melanoma involving the skin primarily affects the back and has a 5-year survival rate of 32% to 42%.⁴ Poor prognosis has been attributed to the high risk for vascular embolization under the lesion.⁵ Histologically, there is marked cell atypia with nuclear and cellular pleomorphism and a high mitotic count. The tumor rarely involves the reticular dermis.^1,2

Polypoid melanomas are rare; however, reported frequency rates cover a wide range. These frequency rates may be due to the definition of polypoid melanoma used by the pathologist issuing the report. One of the most accepted definitions at present is a pigmented macule that progresses in months with a rapid vertical growth, invading the epidermis and the papillary dermis.² The differential diagnosis includes pyogenic granuloma, squamous cell carcinoma, basal cell carcinoma, soft tissue sarcomas, and hemangioma.

Although our patient had a history of melanoma and the polypoid lesion developed from a flat lesion, he was late to seek medical care. The diagnosis of melanoma is made on increasingly smaller lesions with better prognosis, but there still are reports of larger melanomas. This case highlights the role dermatologists serve in the education of patients on their diagnoses and risk factors so that we may be able to diagnose non–life-threatening small lesions. It is important to remember this morphologic variety of melanoma and highlight its rapid progression and poor prognosis.

To the Editor:

An 81-year-old man presented with a nodular polypoid lesion that developed on a flat lesion on the back of 2 years’ duration. The lesion grew progressively over the course of 3 months prior to presentation. The patient had a history of melanoma in situ on the forehead that was treated with conventional surgery with clear surgical margins 6 years prior to the current presentation.

On physical examination the patient had a 4×2-cm ulcerated polypoid lesion on the back. The lesion was pink with a pigmented base. Additionally, 2 pink papules with superficial telangiectases were observed around the main lesion (Figure 1).

The gross section showed an exophytic tumor largely growing above the skin surface (Figure 2). Histopathologic analysis revealed an ulcerated lesion consisting of confluent nest and sheets of epithelioid and spindle atypical cells with numerous mitotic figures and necrotic foci (Figure 3). The thickness of the lesion was 2200 µm, and the mitotic count was 28 mitoses/mm². There also was peritumoral vascular invasion and satellite metastasis within the perilesional hypodermis measuring 0.4 mm. Immunohistochemistry staining for S-100, human melanoma black 45 (HMB-45)(Figure 4), and Melan-A was positive in neoplastic cells.

The dissemination study revealed multiple mediastinal and axillary lymphadenopathies and lesions with metastatic appearance in the brain, liver, pancreas, and muscle, together with peritoneal carcinomatosis. The patient was lost to follow-up and did not follow coadjuvant therapy with interferon alfa.

Polypoid melanoma initially was described as a type of melanoma characterized by an exophytic growth in which most of the tumor is located on the cutaneous surface, together with ulceration.¹ It usually occurs in patients aged 20 to 39 years,² and the reported incidence ranges from 1.9% to 43.3%.¹ It more commonly affects mucosae, including the upper respiratory tract, esophagus, and vagina. Polypoid melanoma has a rapid progression and a poor prognosis.³ Polypoid melanoma involving the skin primarily affects the back and has a 5-year survival rate of 32% to 42%.⁴ Poor prognosis has been attributed to the high risk for vascular embolization under the lesion.⁵ Histologically, there is marked cell atypia with nuclear and cellular pleomorphism and a high mitotic count. The tumor rarely involves the reticular dermis.^1,2

Polypoid melanomas are rare; however, reported frequency rates cover a wide range. These frequency rates may be due to the definition of polypoid melanoma used by the pathologist issuing the report. One of the most accepted definitions at present is a pigmented macule that progresses in months with a rapid vertical growth, invading the epidermis and the papillary dermis.² The differential diagnosis includes pyogenic granuloma, squamous cell carcinoma, basal cell carcinoma, soft tissue sarcomas, and hemangioma.

Although our patient had a history of melanoma and the polypoid lesion developed from a flat lesion, he was late to seek medical care. The diagnosis of melanoma is made on increasingly smaller lesions with better prognosis, but there still are reports of larger melanomas. This case highlights the role dermatologists serve in the education of patients on their diagnoses and risk factors so that we may be able to diagnose non–life-threatening small lesions. It is important to remember this morphologic variety of melanoma and highlight its rapid progression and poor prognosis.

CHICAGO – Matched targeted therapy improved long-term survival in patients with advanced cancer, according to findings from a retrospective analysis of molecularly profiled patients.

Of 3,743 patients tested as part of IMPACT (Initiative for Molecular Profiling and Advanced Cancer Therapy), 1,307 (34.9%) had at least one targetable molecular alteration. Of those, 711 (54.4%) received either matched targeted therapy that was being tested in a clinical trial or – in a small number of cases – therapy with an approved treatment used off label, and 596 (45.6%) received nonmatched therapy, Apostolia-Maria Tsimberidou, MD, reported during a press briefing at the annual meeting of the American Society of Clinical Oncology.

The objective response rates in 697 evaluable matched therapy patients was 16.2% versus 5.4% in 571 evaluable nonmatched patients, and stable disease for at least 6 months occurred in 18.7% and 14.7% of patients, respectively, for an overall disease control rate of 34.9% versus 20.1%, said Dr. Tsimberidou, a professor at the University of Texas MD Anderson Cancer Center, Houston.

Median progression-free survival in those who received matched versus nonmatched therapy was 4.0 months and 2.8 months, respectively (hazard ratio, 0.67), and median overall survival was 9.3 and 7.3 months, respectively (HR, 0.72), she said.

The 3-year overall survival rate was 15% versus 7%, respectively, and 10-year survival was 6% and 1%, respectively.

Patients included in IMPACT had a mean age of 57 years, and 39% were men. They were heavily pretreated (mean number of prior therapies was 4); only 2.8% of patients had no prior treatment. Cancers included gastrointestinal (24.2%), gynecologic (19.4%), breast (13.5%), melanoma (11.9%) and lung (8.7%).

In this video interview, Dr. Tsimberidou describes the rationale, methodology, and findings of IMPACT, including the use of a prognostic scoring system developed as part of the study to predict overall survival based on baseline characteristics, such as baseline p13K/AKT/mTOR pathway molecular alterations, which were shown on multivariate analysis in IMPACT to predict shorter overall survival versus other alterations. Other predictors of shorter survival included liver metastases, elevated lactate dehydrogenase levels, poor functional status, low albumin levels, elevated platelet counts, and age of 60 years or older.

SOURCE: Tsimberidou AM et al. ASCO 2018, Abstract LBA 2553.

CHICAGO – Matched targeted therapy improved long-term survival in patients with advanced cancer, according to findings from a retrospective analysis of molecularly profiled patients.

Of 3,743 patients tested as part of IMPACT (Initiative for Molecular Profiling and Advanced Cancer Therapy), 1,307 (34.9%) had at least one targetable molecular alteration. Of those, 711 (54.4%) received either matched targeted therapy that was being tested in a clinical trial or – in a small number of cases – therapy with an approved treatment used off label, and 596 (45.6%) received nonmatched therapy, Apostolia-Maria Tsimberidou, MD, reported during a press briefing at the annual meeting of the American Society of Clinical Oncology.

The objective response rates in 697 evaluable matched therapy patients was 16.2% versus 5.4% in 571 evaluable nonmatched patients, and stable disease for at least 6 months occurred in 18.7% and 14.7% of patients, respectively, for an overall disease control rate of 34.9% versus 20.1%, said Dr. Tsimberidou, a professor at the University of Texas MD Anderson Cancer Center, Houston.

Median progression-free survival in those who received matched versus nonmatched therapy was 4.0 months and 2.8 months, respectively (hazard ratio, 0.67), and median overall survival was 9.3 and 7.3 months, respectively (HR, 0.72), she said.

The 3-year overall survival rate was 15% versus 7%, respectively, and 10-year survival was 6% and 1%, respectively.

Patients included in IMPACT had a mean age of 57 years, and 39% were men. They were heavily pretreated (mean number of prior therapies was 4); only 2.8% of patients had no prior treatment. Cancers included gastrointestinal (24.2%), gynecologic (19.4%), breast (13.5%), melanoma (11.9%) and lung (8.7%).

In this video interview, Dr. Tsimberidou describes the rationale, methodology, and findings of IMPACT, including the use of a prognostic scoring system developed as part of the study to predict overall survival based on baseline characteristics, such as baseline p13K/AKT/mTOR pathway molecular alterations, which were shown on multivariate analysis in IMPACT to predict shorter overall survival versus other alterations. Other predictors of shorter survival included liver metastases, elevated lactate dehydrogenase levels, poor functional status, low albumin levels, elevated platelet counts, and age of 60 years or older.

SOURCE: Tsimberidou AM et al. ASCO 2018, Abstract LBA 2553.

CHICAGO – Matched targeted therapy improved long-term survival in patients with advanced cancer, according to findings from a retrospective analysis of molecularly profiled patients.

Of 3,743 patients tested as part of IMPACT (Initiative for Molecular Profiling and Advanced Cancer Therapy), 1,307 (34.9%) had at least one targetable molecular alteration. Of those, 711 (54.4%) received either matched targeted therapy that was being tested in a clinical trial or – in a small number of cases – therapy with an approved treatment used off label, and 596 (45.6%) received nonmatched therapy, Apostolia-Maria Tsimberidou, MD, reported during a press briefing at the annual meeting of the American Society of Clinical Oncology.

The objective response rates in 697 evaluable matched therapy patients was 16.2% versus 5.4% in 571 evaluable nonmatched patients, and stable disease for at least 6 months occurred in 18.7% and 14.7% of patients, respectively, for an overall disease control rate of 34.9% versus 20.1%, said Dr. Tsimberidou, a professor at the University of Texas MD Anderson Cancer Center, Houston.

Median progression-free survival in those who received matched versus nonmatched therapy was 4.0 months and 2.8 months, respectively (hazard ratio, 0.67), and median overall survival was 9.3 and 7.3 months, respectively (HR, 0.72), she said.

The 3-year overall survival rate was 15% versus 7%, respectively, and 10-year survival was 6% and 1%, respectively.

Patients included in IMPACT had a mean age of 57 years, and 39% were men. They were heavily pretreated (mean number of prior therapies was 4); only 2.8% of patients had no prior treatment. Cancers included gastrointestinal (24.2%), gynecologic (19.4%), breast (13.5%), melanoma (11.9%) and lung (8.7%).

In this video interview, Dr. Tsimberidou describes the rationale, methodology, and findings of IMPACT, including the use of a prognostic scoring system developed as part of the study to predict overall survival based on baseline characteristics, such as baseline p13K/AKT/mTOR pathway molecular alterations, which were shown on multivariate analysis in IMPACT to predict shorter overall survival versus other alterations. Other predictors of shorter survival included liver metastases, elevated lactate dehydrogenase levels, poor functional status, low albumin levels, elevated platelet counts, and age of 60 years or older.

SOURCE: Tsimberidou AM et al. ASCO 2018, Abstract LBA 2553.

Use of the recently updated AJCC Cancer Staging Manual, 8th edition, produced about 10% better accuracy when interpreting T1a invasive melanomas in a national study.

For stage T1b or greater cases, using the AJCC 8 instead of the AJCC 7 yielded about 6% higher concordance between interpretations and consensus reference diagnoses, said Joann G. Elmore, MD, MPH, of the David Geffen School of Medicine at the University of California, Los Angeles, and her associates. “Intraobserver reproducibility of diagnoses also improved,” but “concordance and reproducibility remain low,” the researchers wrote. The report was published in JAMA Open Network.

For the study, 187 pathologists each interpreted one of five glass slide sets of melanocytic skin biopsies. At least 8 months later, they interpreted the same set again, both times recording their interpretations on the online Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx). Researchers then used AJCC 7 and AJCC 8 criteria to group these interpretations into one of five MPATH-Dx classes. The final analysis included only the 116 cases of invasive melanoma, because changes in the AJCC 8 criteria affected only MPATH-Dx classes IV (T1a) and V (T1b and higher), the investigators explained.

For T1a invasive melanomas, overall concordance between interpretations and consensus diagnoses rose from 44% (95% confidence interval, 41%-48%) under the AJCC 7 criteria to 54% (95% CI, 51%-57%) under the AJCC 8 criteria. For stage T1b or higher lesions, concordance rose from 72% to 78%. Intrapathologist reproducibility improved from 59% to 64% for T1a cases and from 74% to 77% for T1b or higher cases. Thus, the AJCC 8 produced “modest” improvements in concordance and reproducibility over the AJCC 7, the researchers said.

One of the most likely explanations is that the AJCC 8 eliminated dermal mitotic activity as a criterion for T1b melanomas, which is “potentially unreliable” in thin lesions, they added. Persistently low concordance and reproducibility “suggest that conventional histopathology has been parsed to a degree that falls below the limits of reliability,” they concluded.

The National Cancer Institute provided funding. Dr. Elmore disclosed ties to Myriad Genetics, SciBase, and the National Institutes of Health.

SOURCE: Elmore JG et al. JAMA Network Open. 2018 May 18. doi: 10.1001/jamanetworkopen.2018.0083.

Use of the recently updated AJCC Cancer Staging Manual, 8th edition, produced about 10% better accuracy when interpreting T1a invasive melanomas in a national study.

For stage T1b or greater cases, using the AJCC 8 instead of the AJCC 7 yielded about 6% higher concordance between interpretations and consensus reference diagnoses, said Joann G. Elmore, MD, MPH, of the David Geffen School of Medicine at the University of California, Los Angeles, and her associates. “Intraobserver reproducibility of diagnoses also improved,” but “concordance and reproducibility remain low,” the researchers wrote. The report was published in JAMA Open Network.

For the study, 187 pathologists each interpreted one of five glass slide sets of melanocytic skin biopsies. At least 8 months later, they interpreted the same set again, both times recording their interpretations on the online Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx). Researchers then used AJCC 7 and AJCC 8 criteria to group these interpretations into one of five MPATH-Dx classes. The final analysis included only the 116 cases of invasive melanoma, because changes in the AJCC 8 criteria affected only MPATH-Dx classes IV (T1a) and V (T1b and higher), the investigators explained.

For T1a invasive melanomas, overall concordance between interpretations and consensus diagnoses rose from 44% (95% confidence interval, 41%-48%) under the AJCC 7 criteria to 54% (95% CI, 51%-57%) under the AJCC 8 criteria. For stage T1b or higher lesions, concordance rose from 72% to 78%. Intrapathologist reproducibility improved from 59% to 64% for T1a cases and from 74% to 77% for T1b or higher cases. Thus, the AJCC 8 produced “modest” improvements in concordance and reproducibility over the AJCC 7, the researchers said.

One of the most likely explanations is that the AJCC 8 eliminated dermal mitotic activity as a criterion for T1b melanomas, which is “potentially unreliable” in thin lesions, they added. Persistently low concordance and reproducibility “suggest that conventional histopathology has been parsed to a degree that falls below the limits of reliability,” they concluded.

The National Cancer Institute provided funding. Dr. Elmore disclosed ties to Myriad Genetics, SciBase, and the National Institutes of Health.

SOURCE: Elmore JG et al. JAMA Network Open. 2018 May 18. doi: 10.1001/jamanetworkopen.2018.0083.

Use of the recently updated AJCC Cancer Staging Manual, 8th edition, produced about 10% better accuracy when interpreting T1a invasive melanomas in a national study.

For stage T1b or greater cases, using the AJCC 8 instead of the AJCC 7 yielded about 6% higher concordance between interpretations and consensus reference diagnoses, said Joann G. Elmore, MD, MPH, of the David Geffen School of Medicine at the University of California, Los Angeles, and her associates. “Intraobserver reproducibility of diagnoses also improved,” but “concordance and reproducibility remain low,” the researchers wrote. The report was published in JAMA Open Network.

For the study, 187 pathologists each interpreted one of five glass slide sets of melanocytic skin biopsies. At least 8 months later, they interpreted the same set again, both times recording their interpretations on the online Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx). Researchers then used AJCC 7 and AJCC 8 criteria to group these interpretations into one of five MPATH-Dx classes. The final analysis included only the 116 cases of invasive melanoma, because changes in the AJCC 8 criteria affected only MPATH-Dx classes IV (T1a) and V (T1b and higher), the investigators explained.

For T1a invasive melanomas, overall concordance between interpretations and consensus diagnoses rose from 44% (95% confidence interval, 41%-48%) under the AJCC 7 criteria to 54% (95% CI, 51%-57%) under the AJCC 8 criteria. For stage T1b or higher lesions, concordance rose from 72% to 78%. Intrapathologist reproducibility improved from 59% to 64% for T1a cases and from 74% to 77% for T1b or higher cases. Thus, the AJCC 8 produced “modest” improvements in concordance and reproducibility over the AJCC 7, the researchers said.

One of the most likely explanations is that the AJCC 8 eliminated dermal mitotic activity as a criterion for T1b melanomas, which is “potentially unreliable” in thin lesions, they added. Persistently low concordance and reproducibility “suggest that conventional histopathology has been parsed to a degree that falls below the limits of reliability,” they concluded.

The National Cancer Institute provided funding. Dr. Elmore disclosed ties to Myriad Genetics, SciBase, and the National Institutes of Health.

SOURCE: Elmore JG et al. JAMA Network Open. 2018 May 18. doi: 10.1001/jamanetworkopen.2018.0083.

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

bjancin@mdedge.com

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

bjancin@mdedge.com

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

bjancin@mdedge.com

PITTSBURGH – The incidence of many pediatric cancers are on the rise, and the increase is occurring in nearly all demographic groups studied, according to the latest data from the U.S. Centers for Disease Control and Prevention.

Pediatric cancers that increased significantly in incidence from 2001 through 2014, compared with previous time periods, include thyroid carcinoma, hepatic tumors, lymphomas, renal tumors, and brain tumors. Other cancer types remained unchanged, except malignant melanoma, which saw a significant decline in incidence over the same period, reported David A. Siegel, MD, of the Epidemic Intelligence Service at the CDC in Atlanta.

Neil Osterweil/MDedge News

SOURCE: Siegel DA et al. ASPHO 2018, Abstract 605.

PITTSBURGH – The incidence of many pediatric cancers are on the rise, and the increase is occurring in nearly all demographic groups studied, according to the latest data from the U.S. Centers for Disease Control and Prevention.

Pediatric cancers that increased significantly in incidence from 2001 through 2014, compared with previous time periods, include thyroid carcinoma, hepatic tumors, lymphomas, renal tumors, and brain tumors. Other cancer types remained unchanged, except malignant melanoma, which saw a significant decline in incidence over the same period, reported David A. Siegel, MD, of the Epidemic Intelligence Service at the CDC in Atlanta.

Neil Osterweil/MDedge News

SOURCE: Siegel DA et al. ASPHO 2018, Abstract 605.

PITTSBURGH – The incidence of many pediatric cancers are on the rise, and the increase is occurring in nearly all demographic groups studied, according to the latest data from the U.S. Centers for Disease Control and Prevention.

Pediatric cancers that increased significantly in incidence from 2001 through 2014, compared with previous time periods, include thyroid carcinoma, hepatic tumors, lymphomas, renal tumors, and brain tumors. Other cancer types remained unchanged, except malignant melanoma, which saw a significant decline in incidence over the same period, reported David A. Siegel, MD, of the Epidemic Intelligence Service at the CDC in Atlanta.

Neil Osterweil/MDedge News

SOURCE: Siegel DA et al. ASPHO 2018, Abstract 605.

Cancer immunotherapy using checkpoint inhibitors may achieve greater mortality reductions in men than they do in women, new research has suggested.

In a meta-analysis and systematic review published in Lancet Oncology, researchers analyzed 20 randomized, controlled trials of immune checkpoint inhibitors that included detail on overall survival and patients’ sex; altogether, these studies involved 11,351 patients with advanced or metastatic cancers.

They found that while men treated with checkpoint inhibitors had a significant 28% reduced risk of death, compared with male controls, the survival benefit in women was smaller (14% reduced risk of death, compared with female controls).

Fabio Conforti, MD, from the European Institute of Oncology, Milan, and coauthors commented that the magnitude of the difference between the effect seen men and that in women was clinically significant.

“The pooled reduction of risk of death was double the size for male patients than for female patients – a difference that is similar to the size of the difference in survival benefit observed between patients with non–small cell lung cancer with PD-L1 positive (greater than 1%) tumors versus negative tumors, who were treated with anti-PD-1,” they wrote.

This difference between the benefit seen men and that in women was evident across all the subgroups in the study, which included subgroups based on cancer histotype, line of treatment, drugs used, and type of control.

However there was greater heterogeneity in the magnitude of the effect of checkpoint inhibitors on mortality in men than there was in women. The authors suggested this could be explained by the fact that the drugs have lower efficacy in women and this may therefore reduce the variability of results when compared with those in men.

SOURCE: Conforti F et al. Lancet Oncol. 2018 May 16. doi: 10.1016/S1470-2045(18)30261-4.

Cancer immunotherapy using checkpoint inhibitors may achieve greater mortality reductions in men than they do in women, new research has suggested.

In a meta-analysis and systematic review published in Lancet Oncology, researchers analyzed 20 randomized, controlled trials of immune checkpoint inhibitors that included detail on overall survival and patients’ sex; altogether, these studies involved 11,351 patients with advanced or metastatic cancers.

They found that while men treated with checkpoint inhibitors had a significant 28% reduced risk of death, compared with male controls, the survival benefit in women was smaller (14% reduced risk of death, compared with female controls).

Fabio Conforti, MD, from the European Institute of Oncology, Milan, and coauthors commented that the magnitude of the difference between the effect seen men and that in women was clinically significant.

“The pooled reduction of risk of death was double the size for male patients than for female patients – a difference that is similar to the size of the difference in survival benefit observed between patients with non–small cell lung cancer with PD-L1 positive (greater than 1%) tumors versus negative tumors, who were treated with anti-PD-1,” they wrote.

This difference between the benefit seen men and that in women was evident across all the subgroups in the study, which included subgroups based on cancer histotype, line of treatment, drugs used, and type of control.

However there was greater heterogeneity in the magnitude of the effect of checkpoint inhibitors on mortality in men than there was in women. The authors suggested this could be explained by the fact that the drugs have lower efficacy in women and this may therefore reduce the variability of results when compared with those in men.

SOURCE: Conforti F et al. Lancet Oncol. 2018 May 16. doi: 10.1016/S1470-2045(18)30261-4.

Cancer immunotherapy using checkpoint inhibitors may achieve greater mortality reductions in men than they do in women, new research has suggested.

In a meta-analysis and systematic review published in Lancet Oncology, researchers analyzed 20 randomized, controlled trials of immune checkpoint inhibitors that included detail on overall survival and patients’ sex; altogether, these studies involved 11,351 patients with advanced or metastatic cancers.

They found that while men treated with checkpoint inhibitors had a significant 28% reduced risk of death, compared with male controls, the survival benefit in women was smaller (14% reduced risk of death, compared with female controls).

Fabio Conforti, MD, from the European Institute of Oncology, Milan, and coauthors commented that the magnitude of the difference between the effect seen men and that in women was clinically significant.

“The pooled reduction of risk of death was double the size for male patients than for female patients – a difference that is similar to the size of the difference in survival benefit observed between patients with non–small cell lung cancer with PD-L1 positive (greater than 1%) tumors versus negative tumors, who were treated with anti-PD-1,” they wrote.

This difference between the benefit seen men and that in women was evident across all the subgroups in the study, which included subgroups based on cancer histotype, line of treatment, drugs used, and type of control.

However there was greater heterogeneity in the magnitude of the effect of checkpoint inhibitors on mortality in men than there was in women. The authors suggested this could be explained by the fact that the drugs have lower efficacy in women and this may therefore reduce the variability of results when compared with those in men.

SOURCE: Conforti F et al. Lancet Oncol. 2018 May 16. doi: 10.1016/S1470-2045(18)30261-4.

CHICAGO – Routine use of an N95 mask during electrocautery is an effective and inexpensive way for dermatologic surgeons to protect themselves from toxic, airborne particulate matter in the smoke generated during the procedure, Emily de Golian, MD, said at the annual meeting of the American College of Mohs Surgery.

“Our data suggest clear dominance of N95 masks at filtering electrocautery particulate matter over commonly utilized basic procedural masks, as well as superiority to the laser masks that are used in hair removal procedures and ablative procedures in cosmetic clinics,” commented Dr. de Golian, a Mohs micrographic surgery fellow at the University of California, San Diego.

Bruce Jancin/MDedge News

ninuns/iStock/Getty Images Plus

bjancin@mdedge.com

CHICAGO – Routine use of an N95 mask during electrocautery is an effective and inexpensive way for dermatologic surgeons to protect themselves from toxic, airborne particulate matter in the smoke generated during the procedure, Emily de Golian, MD, said at the annual meeting of the American College of Mohs Surgery.

“Our data suggest clear dominance of N95 masks at filtering electrocautery particulate matter over commonly utilized basic procedural masks, as well as superiority to the laser masks that are used in hair removal procedures and ablative procedures in cosmetic clinics,” commented Dr. de Golian, a Mohs micrographic surgery fellow at the University of California, San Diego.

Bruce Jancin/MDedge News

ninuns/iStock/Getty Images Plus

bjancin@mdedge.com

CHICAGO – Routine use of an N95 mask during electrocautery is an effective and inexpensive way for dermatologic surgeons to protect themselves from toxic, airborne particulate matter in the smoke generated during the procedure, Emily de Golian, MD, said at the annual meeting of the American College of Mohs Surgery.

“Our data suggest clear dominance of N95 masks at filtering electrocautery particulate matter over commonly utilized basic procedural masks, as well as superiority to the laser masks that are used in hair removal procedures and ablative procedures in cosmetic clinics,” commented Dr. de Golian, a Mohs micrographic surgery fellow at the University of California, San Diego.

Bruce Jancin/MDedge News

ninuns/iStock/Getty Images Plus

bjancin@mdedge.com

Checkpoint inhibitors got to melanoma, non–small cell lung cancer, and renal cell carcinoma patients quickly in clinical practice after Food and Drug Administration approval – usually within 4 months – but the patients treated in clinical settings tended to be older than those treated in trials, which has caused concern about whether real-world efficacy will prove to be the same, according to a study in JAMA Oncology.

“Such rapid adoption stands in contrast to older estimates that suggest it takes years or even decades for new treatments to be adopted,” wrote lead author Cary Gross, MD, professor of medicine at Yale University, New Haven, and his coauthors. “We found significant differences in age between patients treated in practice and those treated in trials, which highlights the need to clarify the risks and benefits of checkpoint inhibitors in general populations of patients.”

Researchers drew data on nivolumab and pembrolizumab use from the Flatiron Health longitudinal EHR database, which included 233 academic and community oncology practices. In each of the three disease cohorts, adoption was seen within 4 months for at least 60% of patients. Uptake was quickest for the melanoma patients, 76% of whom received a checkpoint inhibitor within 4 months, investigators wrote. Factors for the fast adoption could include high disease severity, a preference for novelty, perceived gains over existing treatments, and promotional activities, such as media reports and advertising directly to consumers, they wrote.

More patients in real-world practice were aged 65 years or older, ranging from as little as 61% at the lowest end of the range at one center to as much as 64% at the highest end at another. In the clinical trials, the percentage of patients aged 65 years or older ranged from 32% in one trial to 41% in another. Researchers wrote that these higher real-world rates are concerning because there are still questions regarding whether differences in immune responses will cause differences in efficacy between older and younger patients, as well as safety considerations among different age groups.

“Although data suggest that outcomes are similar between older and younger patients receiving anti–PD-1 agents for melanoma, there is little evidence to guide anti–PD-1 treatment of older patients with NSCLC [non–small cell lung cancer],” Dr. Gross and his coinvestigators wrote.

Investigators wrote that the findings are cause for caution.

“As FDA officials develop more flexible standards for approval, which the 21st Century Cures Act requires them to do, it is possible that many patients will receive drugs before much is known about clinical outcomes,” Dr. Gross said. “Further integrations of real-world evidence might allow the FDA to better assess the drugs that they approve on the basis of nonrepresentative trial participants.”

SOURCE: Gross C et al. JAMA Oncol. 2018 May 10. doi: 10.1001/jamaoncol.2018.0798.






 

Checkpoint inhibitors got to melanoma, non–small cell lung cancer, and renal cell carcinoma patients quickly in clinical practice after Food and Drug Administration approval – usually within 4 months – but the patients treated in clinical settings tended to be older than those treated in trials, which has caused concern about whether real-world efficacy will prove to be the same, according to a study in JAMA Oncology.

“Such rapid adoption stands in contrast to older estimates that suggest it takes years or even decades for new treatments to be adopted,” wrote lead author Cary Gross, MD, professor of medicine at Yale University, New Haven, and his coauthors. “We found significant differences in age between patients treated in practice and those treated in trials, which highlights the need to clarify the risks and benefits of checkpoint inhibitors in general populations of patients.”

Researchers drew data on nivolumab and pembrolizumab use from the Flatiron Health longitudinal EHR database, which included 233 academic and community oncology practices. In each of the three disease cohorts, adoption was seen within 4 months for at least 60% of patients. Uptake was quickest for the melanoma patients, 76% of whom received a checkpoint inhibitor within 4 months, investigators wrote. Factors for the fast adoption could include high disease severity, a preference for novelty, perceived gains over existing treatments, and promotional activities, such as media reports and advertising directly to consumers, they wrote.

More patients in real-world practice were aged 65 years or older, ranging from as little as 61% at the lowest end of the range at one center to as much as 64% at the highest end at another. In the clinical trials, the percentage of patients aged 65 years or older ranged from 32% in one trial to 41% in another. Researchers wrote that these higher real-world rates are concerning because there are still questions regarding whether differences in immune responses will cause differences in efficacy between older and younger patients, as well as safety considerations among different age groups.

“Although data suggest that outcomes are similar between older and younger patients receiving anti–PD-1 agents for melanoma, there is little evidence to guide anti–PD-1 treatment of older patients with NSCLC [non–small cell lung cancer],” Dr. Gross and his coinvestigators wrote.

Investigators wrote that the findings are cause for caution.

“As FDA officials develop more flexible standards for approval, which the 21st Century Cures Act requires them to do, it is possible that many patients will receive drugs before much is known about clinical outcomes,” Dr. Gross said. “Further integrations of real-world evidence might allow the FDA to better assess the drugs that they approve on the basis of nonrepresentative trial participants.”

SOURCE: Gross C et al. JAMA Oncol. 2018 May 10. doi: 10.1001/jamaoncol.2018.0798.






 

Checkpoint inhibitors got to melanoma, non–small cell lung cancer, and renal cell carcinoma patients quickly in clinical practice after Food and Drug Administration approval – usually within 4 months – but the patients treated in clinical settings tended to be older than those treated in trials, which has caused concern about whether real-world efficacy will prove to be the same, according to a study in JAMA Oncology.

“Such rapid adoption stands in contrast to older estimates that suggest it takes years or even decades for new treatments to be adopted,” wrote lead author Cary Gross, MD, professor of medicine at Yale University, New Haven, and his coauthors. “We found significant differences in age between patients treated in practice and those treated in trials, which highlights the need to clarify the risks and benefits of checkpoint inhibitors in general populations of patients.”

Researchers drew data on nivolumab and pembrolizumab use from the Flatiron Health longitudinal EHR database, which included 233 academic and community oncology practices. In each of the three disease cohorts, adoption was seen within 4 months for at least 60% of patients. Uptake was quickest for the melanoma patients, 76% of whom received a checkpoint inhibitor within 4 months, investigators wrote. Factors for the fast adoption could include high disease severity, a preference for novelty, perceived gains over existing treatments, and promotional activities, such as media reports and advertising directly to consumers, they wrote.

More patients in real-world practice were aged 65 years or older, ranging from as little as 61% at the lowest end of the range at one center to as much as 64% at the highest end at another. In the clinical trials, the percentage of patients aged 65 years or older ranged from 32% in one trial to 41% in another. Researchers wrote that these higher real-world rates are concerning because there are still questions regarding whether differences in immune responses will cause differences in efficacy between older and younger patients, as well as safety considerations among different age groups.

“Although data suggest that outcomes are similar between older and younger patients receiving anti–PD-1 agents for melanoma, there is little evidence to guide anti–PD-1 treatment of older patients with NSCLC [non–small cell lung cancer],” Dr. Gross and his coinvestigators wrote.

Investigators wrote that the findings are cause for caution.

“As FDA officials develop more flexible standards for approval, which the 21st Century Cures Act requires them to do, it is possible that many patients will receive drugs before much is known about clinical outcomes,” Dr. Gross said. “Further integrations of real-world evidence might allow the FDA to better assess the drugs that they approve on the basis of nonrepresentative trial participants.”

SOURCE: Gross C et al. JAMA Oncol. 2018 May 10. doi: 10.1001/jamaoncol.2018.0798.






 

Early detection of melanoma, which is known to improve survival rates, remains a challenge for dermatologists. Suspicious pigmented lesions typically are evaluated via clinical examination and dermoscopy; however, new technologies are being developed to provide additional objective information for clinicians to incorporate into their biopsy decisions.

Multispectral digital skin lesion analysis (MSDSLA) uses 10 bands of visible and near-infrared light (430–950 nm) to image and analyze pigmented skin lesions (PSLs) down to 2.5 mm below the skin surface and measures the distribution of melanin using 75 unique algorithms to determine the degree of the morphologic disorder. Using a logical regression model previously validated on a set of 1632 PSLs, the probability of melanoma and probability of being a melanoma/PSL of high-risk malignant potential are then provided to the clinician.¹

In this study, we analyzed aggregate data from 7 prior studies^2-8 to better determine how MSDSLA impacts the biopsy decisions of dermatologists and nondermatologists following clinical examination and dermoscopic evaluation of PSLs.

Methods

A total of 855 practitioners (657 dermatologists, 126 dermatology residents, 72 nondermatologists [ie, primary care physicians, physician assistants, nurse practitioners]) in 7 prior reader studies (Table)^2-8 were shown a total of 62 clinical (distant and close-up) and dermoscopic images of PSLs (13 invasive melanomas, 10 melanomas in situ, 7 high-grade dysplastic nevi, 32 benign skin lesions including low-grade dysplastic nevi) previously analyzed by MSDSLA.^2-8 For each lesion evaluated, the practitioners were first asked if they would biopsy based on their review of the clinical and dermoscopic images and were asked again when given the associated MSDSLA information. Data were aggregated across all participants for the individual lesions presented in each reader study. Biopsy decisions were compared overall after evaluation of clinical and dermoscopic findings and then after evaluation of MSDSLA findings. Statistical analyses were performed using t-test and χ² analysis for proportions where appropriate.

Results

Overall sensitivity for the detection of melanoma or other high-grade PSLs improved from 70% on clinical and dermoscopic evaluation to 88% after MSDSLA information was provided (P<.0001), and specificity increased from 52% to 58% (P<.001). Diagnostic accuracy also improved from 59% on clinical evaluation to 69% after review of MSDSLA findings (P<.0001). The positive predictive value of biopsy decisions was 47% following clinical evaluation, which improved to 56% after evaluation of MSDSLA findings (P<.001), and the negative predictive value increased from 74% to 89% (P<.0001). The overall percentage of lesions selected for biopsy did not significantly change following MSDSLA data integration (57% vs 60%)(Figure). Given that similar numbers of lesions were biopsied with improved sensitivity and specificity, the integration of MSDSLA data into the biopsy decision led to an improved biopsy ratio (ratio of melanomas biopsied to total biopsies) and fewer unnecessary biopsies.

Comment

Our broad analysis further supported the findings of prior studies that decisions to biopsy clinically suspicious PSLs are more sensitive, specific, and accurate when practitioners are provided MSDSLA information following clinical examination.^2-8With no significant increase in the number of biopsies performed, the fact that all 5 of the standard diagnostic evaluation metrics (sensitivity, specificity, diagnostic accuracy, positive predictive value, negative predictive value) were improved after MSDSLA information was provided additionally supported this conclusion.

Given the evolution in health care economics, it is clear that greater emphasis will continue to be placed on superior, evidence-based, effective care. The reported diagnostic sensitivities and specificities of clinical evaluation and dermoscopy for melanoma detection vary widely throughout the literature, with sensitivities ranging from 58% to over 90% and specificities ranging from 77% to 99%.^9-11Diagnostic performance generally has been found to be higher among dermatologists than nondermatologists and is highest in specialized pigmented lesion clinics.¹²

Our study had several limitations. For this analysis to be more representative of lesion biopsy selection in the clinical setting, biopsy sensitivity (correctly identifying lesions appropriate for biopsy) vs melanoma sensitivity (identifying a lesion as melanoma) was used.¹³ The overall sensitivity found was within the range of prior studies,^2-8 but this approach may have potentially led to a lower specificity due to an increased number of lesions biopsied. Additionally, the melanomas selected for these studies were early (malignant melanoma in situ or mean thickness of invasive malignant melanoma of 0.3 mm), and the nonmelanomas (including low-grade dysplastic nevi) were not necessarily diagnostically straightforward. This may have led to the clinical and dermoscopic sensitivity and specificity noted being lower than in some prior studies.^9-11

The risk of missing a melanoma with MSDSLA devices has led manufacturers to strive for a high sensitivity for their devices, leading to lower specificity as a consequence. For this reason and other ambiguous practical considerations (eg, device and patient costs, difficulty with insurance reimbursement), the adoption of this technology into routine clinical practice has remained relatively static; however, using enhanced diagnostic technologies such as MSDSLA may help with more accurate identification of high-risk PSLs, thereby leading to earlier detection and overall less expensive, more cost-effective treatment of melanoma.

Early detection of melanoma, which is known to improve survival rates, remains a challenge for dermatologists. Suspicious pigmented lesions typically are evaluated via clinical examination and dermoscopy; however, new technologies are being developed to provide additional objective information for clinicians to incorporate into their biopsy decisions.

Multispectral digital skin lesion analysis (MSDSLA) uses 10 bands of visible and near-infrared light (430–950 nm) to image and analyze pigmented skin lesions (PSLs) down to 2.5 mm below the skin surface and measures the distribution of melanin using 75 unique algorithms to determine the degree of the morphologic disorder. Using a logical regression model previously validated on a set of 1632 PSLs, the probability of melanoma and probability of being a melanoma/PSL of high-risk malignant potential are then provided to the clinician.¹

In this study, we analyzed aggregate data from 7 prior studies^2-8 to better determine how MSDSLA impacts the biopsy decisions of dermatologists and nondermatologists following clinical examination and dermoscopic evaluation of PSLs.

Methods

A total of 855 practitioners (657 dermatologists, 126 dermatology residents, 72 nondermatologists [ie, primary care physicians, physician assistants, nurse practitioners]) in 7 prior reader studies (Table)^2-8 were shown a total of 62 clinical (distant and close-up) and dermoscopic images of PSLs (13 invasive melanomas, 10 melanomas in situ, 7 high-grade dysplastic nevi, 32 benign skin lesions including low-grade dysplastic nevi) previously analyzed by MSDSLA.^2-8 For each lesion evaluated, the practitioners were first asked if they would biopsy based on their review of the clinical and dermoscopic images and were asked again when given the associated MSDSLA information. Data were aggregated across all participants for the individual lesions presented in each reader study. Biopsy decisions were compared overall after evaluation of clinical and dermoscopic findings and then after evaluation of MSDSLA findings. Statistical analyses were performed using t-test and χ² analysis for proportions where appropriate.

Results

Overall sensitivity for the detection of melanoma or other high-grade PSLs improved from 70% on clinical and dermoscopic evaluation to 88% after MSDSLA information was provided (P<.0001), and specificity increased from 52% to 58% (P<.001). Diagnostic accuracy also improved from 59% on clinical evaluation to 69% after review of MSDSLA findings (P<.0001). The positive predictive value of biopsy decisions was 47% following clinical evaluation, which improved to 56% after evaluation of MSDSLA findings (P<.001), and the negative predictive value increased from 74% to 89% (P<.0001). The overall percentage of lesions selected for biopsy did not significantly change following MSDSLA data integration (57% vs 60%)(Figure). Given that similar numbers of lesions were biopsied with improved sensitivity and specificity, the integration of MSDSLA data into the biopsy decision led to an improved biopsy ratio (ratio of melanomas biopsied to total biopsies) and fewer unnecessary biopsies.

Comment

Our broad analysis further supported the findings of prior studies that decisions to biopsy clinically suspicious PSLs are more sensitive, specific, and accurate when practitioners are provided MSDSLA information following clinical examination.^2-8With no significant increase in the number of biopsies performed, the fact that all 5 of the standard diagnostic evaluation metrics (sensitivity, specificity, diagnostic accuracy, positive predictive value, negative predictive value) were improved after MSDSLA information was provided additionally supported this conclusion.

Given the evolution in health care economics, it is clear that greater emphasis will continue to be placed on superior, evidence-based, effective care. The reported diagnostic sensitivities and specificities of clinical evaluation and dermoscopy for melanoma detection vary widely throughout the literature, with sensitivities ranging from 58% to over 90% and specificities ranging from 77% to 99%.^9-11Diagnostic performance generally has been found to be higher among dermatologists than nondermatologists and is highest in specialized pigmented lesion clinics.¹²

Our study had several limitations. For this analysis to be more representative of lesion biopsy selection in the clinical setting, biopsy sensitivity (correctly identifying lesions appropriate for biopsy) vs melanoma sensitivity (identifying a lesion as melanoma) was used.¹³ The overall sensitivity found was within the range of prior studies,^2-8 but this approach may have potentially led to a lower specificity due to an increased number of lesions biopsied. Additionally, the melanomas selected for these studies were early (malignant melanoma in situ or mean thickness of invasive malignant melanoma of 0.3 mm), and the nonmelanomas (including low-grade dysplastic nevi) were not necessarily diagnostically straightforward. This may have led to the clinical and dermoscopic sensitivity and specificity noted being lower than in some prior studies.^9-11

The risk of missing a melanoma with MSDSLA devices has led manufacturers to strive for a high sensitivity for their devices, leading to lower specificity as a consequence. For this reason and other ambiguous practical considerations (eg, device and patient costs, difficulty with insurance reimbursement), the adoption of this technology into routine clinical practice has remained relatively static; however, using enhanced diagnostic technologies such as MSDSLA may help with more accurate identification of high-risk PSLs, thereby leading to earlier detection and overall less expensive, more cost-effective treatment of melanoma.

Early detection of melanoma, which is known to improve survival rates, remains a challenge for dermatologists. Suspicious pigmented lesions typically are evaluated via clinical examination and dermoscopy; however, new technologies are being developed to provide additional objective information for clinicians to incorporate into their biopsy decisions.

Multispectral digital skin lesion analysis (MSDSLA) uses 10 bands of visible and near-infrared light (430–950 nm) to image and analyze pigmented skin lesions (PSLs) down to 2.5 mm below the skin surface and measures the distribution of melanin using 75 unique algorithms to determine the degree of the morphologic disorder. Using a logical regression model previously validated on a set of 1632 PSLs, the probability of melanoma and probability of being a melanoma/PSL of high-risk malignant potential are then provided to the clinician.¹

In this study, we analyzed aggregate data from 7 prior studies^2-8 to better determine how MSDSLA impacts the biopsy decisions of dermatologists and nondermatologists following clinical examination and dermoscopic evaluation of PSLs.

Methods

A total of 855 practitioners (657 dermatologists, 126 dermatology residents, 72 nondermatologists [ie, primary care physicians, physician assistants, nurse practitioners]) in 7 prior reader studies (Table)^2-8 were shown a total of 62 clinical (distant and close-up) and dermoscopic images of PSLs (13 invasive melanomas, 10 melanomas in situ, 7 high-grade dysplastic nevi, 32 benign skin lesions including low-grade dysplastic nevi) previously analyzed by MSDSLA.^2-8 For each lesion evaluated, the practitioners were first asked if they would biopsy based on their review of the clinical and dermoscopic images and were asked again when given the associated MSDSLA information. Data were aggregated across all participants for the individual lesions presented in each reader study. Biopsy decisions were compared overall after evaluation of clinical and dermoscopic findings and then after evaluation of MSDSLA findings. Statistical analyses were performed using t-test and χ² analysis for proportions where appropriate.

Results

Overall sensitivity for the detection of melanoma or other high-grade PSLs improved from 70% on clinical and dermoscopic evaluation to 88% after MSDSLA information was provided (P<.0001), and specificity increased from 52% to 58% (P<.001). Diagnostic accuracy also improved from 59% on clinical evaluation to 69% after review of MSDSLA findings (P<.0001). The positive predictive value of biopsy decisions was 47% following clinical evaluation, which improved to 56% after evaluation of MSDSLA findings (P<.001), and the negative predictive value increased from 74% to 89% (P<.0001). The overall percentage of lesions selected for biopsy did not significantly change following MSDSLA data integration (57% vs 60%)(Figure). Given that similar numbers of lesions were biopsied with improved sensitivity and specificity, the integration of MSDSLA data into the biopsy decision led to an improved biopsy ratio (ratio of melanomas biopsied to total biopsies) and fewer unnecessary biopsies.

Comment

Our broad analysis further supported the findings of prior studies that decisions to biopsy clinically suspicious PSLs are more sensitive, specific, and accurate when practitioners are provided MSDSLA information following clinical examination.^2-8With no significant increase in the number of biopsies performed, the fact that all 5 of the standard diagnostic evaluation metrics (sensitivity, specificity, diagnostic accuracy, positive predictive value, negative predictive value) were improved after MSDSLA information was provided additionally supported this conclusion.

Given the evolution in health care economics, it is clear that greater emphasis will continue to be placed on superior, evidence-based, effective care. The reported diagnostic sensitivities and specificities of clinical evaluation and dermoscopy for melanoma detection vary widely throughout the literature, with sensitivities ranging from 58% to over 90% and specificities ranging from 77% to 99%.^9-11Diagnostic performance generally has been found to be higher among dermatologists than nondermatologists and is highest in specialized pigmented lesion clinics.¹²

Our study had several limitations. For this analysis to be more representative of lesion biopsy selection in the clinical setting, biopsy sensitivity (correctly identifying lesions appropriate for biopsy) vs melanoma sensitivity (identifying a lesion as melanoma) was used.¹³ The overall sensitivity found was within the range of prior studies,^2-8 but this approach may have potentially led to a lower specificity due to an increased number of lesions biopsied. Additionally, the melanomas selected for these studies were early (malignant melanoma in situ or mean thickness of invasive malignant melanoma of 0.3 mm), and the nonmelanomas (including low-grade dysplastic nevi) were not necessarily diagnostically straightforward. This may have led to the clinical and dermoscopic sensitivity and specificity noted being lower than in some prior studies.^9-11

The risk of missing a melanoma with MSDSLA devices has led manufacturers to strive for a high sensitivity for their devices, leading to lower specificity as a consequence. For this reason and other ambiguous practical considerations (eg, device and patient costs, difficulty with insurance reimbursement), the adoption of this technology into routine clinical practice has remained relatively static; however, using enhanced diagnostic technologies such as MSDSLA may help with more accurate identification of high-risk PSLs, thereby leading to earlier detection and overall less expensive, more cost-effective treatment of melanoma.