Acta Dermato-Venereologica 97-10CompleteContent | Page 20

1219 CLINICAL REPORT Seven Non-melanoma Features to Rule Out Facial Melanoma Philipp TSCHANDL 1 , Alessio GAMBARDELLA 2 , Amélie BOESPFLUG 3 , Teresa DEINLEIN 4 , Vincenzo DE GIORGI 5 , Harald KITTLER 1 , Aimilios LALLAS 6 , Josep MALVEHY 7 , Elvira MOSCARELLA 8 , Susana PUIG 7 , Massimiliano SCALVENZI 9 , Luc THOMAS 3 , Iris ZALAUDEK 4 , Roberto ALFANO 10 and Giuseppe ARGENZIANO 2 Department of Dermatology, Medical University of Vienna, Vienna, Austria, 2 Dermatology Unit, Second University of Naples, Naples, Italy, 3 Service de Dermatologie, Centre Hospitalier Universitaire de Lyon, Lyon, France, 4 Non Melanoma Skin Cancer Unit, Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria, 5 Department of Dermatology, University of Florence, Florence, Italy, 6 First Department of Dermatology, Aristotle University, Thessaloniki, Greece, 7 Melanoma Unit, Departments of Dermatology, Hospital Clínic de Barcelona, IDIBAPS, Barcelona University, Centre of Biomedical Research on Rare Diseases (CIBERER), ISCIII, Barcelona, Spain, 8 Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, 9 Department of Dermatology, University of Naples Federico II, and 10 Department of Anesthesiology, Surgery and Emergency, Second University of Naples, Naples, Italy 1 Facial melanoma is difficult to diagnose and der- matoscopic features are often subtle. Dermatoscopic non-melanoma patterns may have a comparable di- agnostic value. In this pilot study, facial lesions were collected retrospectively, resulting in a case set of 339 melanomas and 308 non-melanomas. Lesions were evaluated for the prevalence (> 50% of lesional sur- face) of 7 dermatoscopic non-melanoma features: scales, white follicles, erythema/reticular vessels, re- ticular and/or curved lines/fingerprints, structureless brown colour, sharp demarcation, and classic criteria of seborrhoeic keratosis. Melanomas had a lower num- ber of non-melanoma patterns (p < 0.001). Scoring a lesion suspicious when no prevalent non-melanoma pattern is found resulted in a sensitivity of 88.5% and a specificity of 66.9% for the diagnosis of melanoma. Specificity was higher for solar lentigo (78.8%) and seborrhoeic keratosis (74.3%) and lower for actinic keratosis (61.4%) and lichenoid keratosis (25.6%). Evaluation of prevalent non-melanoma patterns can provide slightly lower sensitivity and higher specificity in detecting facial melanoma compared with already known malignant features. Key words: dermatoscopy; dermoscopy; face; melanoma; len- tigo maligna; diagnosis. Accepted Jul 31, 2017; Epub ahead of print Aug 1, 2017 Acta Derm Venereol 2017; 97: 1219–1224. Corr: Giuseppe Argenziano, Dermatology Unit, Second University of Naples, Via Pansini 5, IT-80131 Naples, Italy. E-mail: [email protected] F acial flat pigmented lesions are a diagnostic chal- lenge clinically and dermatoscopically, because many benign lesions show some degree of malignant features, and early melanoma may exhibit only subtle malignant criteria. The dermatoscopic presentation of facial melanoma (FM) was first described by Schiffner et al. (1) and Stolz et al. (2), followed by several studies (3–10) reporting additional morphological clues. Ho- wever, the differentiation of FM from pigmented actinic keratosis (pAK) remains one of the greatest challenges (4, 10). For example, classic features of FM, such as rhomboidal structures, can be seen in both pAK and FM (9). Additional benign lesions, especially solar lentigines (SL) with regressive features (lichenoid keratosis; lichen planus-like keratosis (LPLK); seborrhoeic keratosis or solar lentigo in regression), may show features that overlap with FM. An important clue to malignancy is the presence of grey structures that, although having a good sensitivity (85.1%), reach a specificity of only 39.7% (9). In addition, recognizing grey colour dermatoscopically is a challenge for inexperienced physicians (personal observation, PT and GA), thus a method based on easily recognizable features is urgently needed to improve the early recognition of FM (11). The aim of this study was to test an algorithm compo- sed of negative criteria for differentiating early melanoma from flat benign lesions of the head/neck region. For this method, a lesion is scored “benign” when any prevalent non-melanoma feature is found, and “suspicious” when none or only non-prevalent non-melanoma features are found. MATERIALS AND METHODS Dermatoscopic images, acquired using polarized and non-polari- zed light, from flat lesions located on the head/neck region were se- lected from the databases of 7 clinics for pigmented lesions in Italy, Austria, France and Spain. Retrospectively, histopathologically diagnosed early melanomas (in situ or less than 0.7 mm thick), SL, early seborrhoeic keratosis (SK), pAK, and LPLK were retrieved from the image databases of the collaborating centres. To include a representative number of SL that were not excised, a random sample of flat pigmented lesions that were followed longitudinally and examined by confocal microscopy (between 2014 and 2015) were included. If the lesion was diagnosed as benign by confocal microscopy, it was not excised. If the lesion was doubtful under confocal microscopy, a histopathological diagnosis was obtained before inclusion. A benign lesion might also be included if it was monitored for at least one year without change. For this pilot study, no sample size calculation was per formed. Age, sex, diagnosis (either histopathological diagnosis, confo- cal diagnosis or diagnosis after 1-year follow-up) and eventual Breslow thickness were collected in a Microsoft Excel ® file. For each lesion, 1 dermatoscopic image was evaluated separately in a blinded fashion by 2 observers (AG, RA). A third observer (GA) was consulted when there was disagreement between the 2 main observers. The following 7 non-melanoma features were scored as absent, present (but not prevalent), and prevalent (feature found in more than 50% of the lesion surface): 1) scales (pigmented or non-pigmented); 2) white follicles (including white circles, This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2017 Acta Dermato-Venereologica. doi: 10.2340/00015555-2759 Acta Derm Venereol 2017; 97: 1219–1224