Performance of the “if in doubt, cut it out” rule for the management of nodular melanoma
Keywords:
nodular melanoma, number needed to excise, skin cancer, dermatoscopyAbstract
Background: The recognition of nodular melanoma is clinically challenging, and the diagnostic accuracy of dermoscopy and confocal microscopy is lower than for superficial spreading melanoma.
Objectives: To test a management strategy consisting in the excision of any nodular lesion that cannot be confidently and precisely classified as a benign tumor after clinical and dermoscopic examination.
Methods: Clinical and dermoscopic images of excised nodular lesions were retrospectively collected and evaluated. The evaluators were asked to record the level of diagnostic confidence for each lesion, by declaring if they were confident or doubtful about the given diagnosis. The NNE (number needed to excise) value was used to evaluate the efficacy of the proposed method.
Results: A total of 1,319 excised nodular lesions formed the study set. The NNE for any malignancy was 3.9 (634/164), while the NNE for melanoma was 13.2 (634/48). NNE for hypo and amelanotic melanoma was 27.3 (327/12).
Conclusions: Excising doubtful nodular lesions seems to be an effective management strategy not to miss nodular melanoma, resulting in an acceptable rate of unnecessary excision of benign lesions.
References
Liu W, Dowling JP, Murray WK, et al. Rate of growth in melanomas: characteristics and associations of rapidly growing melanomas. Arch Dermatol. 2006;142(12):1551–1558. PubMed CrossRef
Mar V, Roberts H, Wolfe R, English DR, Kelly JW. Nodular melanoma: a distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia. J Am Acad Dermatol. 2013;68(4):568-575. PubMed CrossRef
Rigel DS, Friedman RJ, Kopf AW, Polsky D. ABCDE–an evolving concept in the early detection of melanoma. Arch Dermatol. 2005;141(8):1032-1034. PubMed CrossRef
Lin MJ, Mar V, McLean C, Wolfe R, Kelly JW. Diagnostic accuracy of malignant melanoma according to subtype. Australas J Dermatol. 2014;55(1):35-42. PubMed CrossRef
Rigel DS, Russak J, Friedman R. The evolution of melanoma diagnosis: 25 years beyond the ABCDs. CA Cancer J Clin. 2010;60(5):301-316. PubMed CrossRef
Kelly JW, Chamberlain AJ, Staples MP, McAvoy B. Nodular melanoma. No longer as simple as ABC. Aust Fam Physician. 2003;32(9):706-709. PubMed
Kelly JW. Nodular melanoma: how current approaches to early detection are failing. J Drugs Dermatol. 2005;4(6):790-793. PubMed
Menzies SW, Moloney FJ, Byth K, et al. Dermoscopic evaluation of nodular melanoma. JAMA Dermatol. 2013;149(6):699-709. PubMed CrossRef
Argenziano G, Longo C, Cameron A, et al. Blue-black rule: a simple dermoscopic clue to recognize pigmented nodular melanoma. Br J Dermatol. 2011;165(6):1251-1255. PubMed CrossRef
Kalkhoran S, Milne O, Zalaudek I, et al. Historical, clinical, and dermoscopic characteristics of thin nodular melanoma. Arch Dermatol. 2010;146(3):311-318. PubMed CrossRef
Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol. 2008;144(9):1120-1127. PubMed CrossRef
Cavicchini S, Tourlaki A, Bottini S. Dermoscopic vascular patterns in nodular “pure” amelanotic melanoma. Arch Dermatol. 2007;143(4):556. PubMed CrossRef
Menzies SW, Ingvar C, Crotty KA, McCarthy WH. Frequency and morphologic characteristics of invasive melanomas lacking specific surface microscopic features. Arch Dermatol. 1996;132(10):1178-1182. PubMed CrossRef
Pizzichetta MA, Kittler H, Stanganelli I, et al. Italian Melanoma Intergroup. Pigmented nodular melanoma: the predictive value of dermoscopic features using multivariate analysis. Br J Dermatol. 2015 Jul;173(1):106-114. PubMed CrossRef
Carli P, De Giorgi V, Palli D, et al. Patterns of detection of superficial spreading and nodular-type melanoma: a multicenter Italian study. Dermatol Surg. 2004;30(11):1371-1375. PubMed CrossRef
Segura S, Pellacani G, Puig S, et al. In vivo microscopic features of nodular melanomas: dermoscopy, confocal microscopy, and histopathologic correlates. Arch Dermatol. 2008;144(10):1311-1320. PubMed CrossRef
Longo C, Farnetani F, Ciardo S, et al. Is confocal microscopy a valuable tool in diagnosing nodular lesions? A study of 140 cases. Br J Dermatol. 2013;169(1):58-67.
Longo C, Farnetani F, Moscarella E, et al. Can noninvasive imaging tools potentially predict the risk of ulceration in invasive melanomas showing blue and black colors? Melanoma Res. 2013;23(2):125-131. PubMed CrossRef
Lallas A, Zalaudek I, Apalla Z, et al. Management rules to detect melanoma. Dermatology. 2013;226(1):52-60. PubMed CrossRef
English DR, Del Mar C, Burton RC. Factors influencing the number needed to excise: excision rates of pigmented lesions by general practitioners. Med J Aust. 2004; 80:16–19. PubMed
Hansen C, Wilkinson D, Hansen M, Argenziano G. How good are skin cancer clinics at melanoma detection? Number needed to treat variability across a national clinic group in Australia. J Am Acad Dermatol. 2009;61:599–604. PubMed CrossRef
Ahnlide I, Nielsen K, Bjellerup M. Diagnosis of pigmented skin tumours in a dermatological setting: different aspects of the number needed to excise as a measure of efficiency. Acta Derm Venereol. 2014;94(6):683-686. PubMed CrossRef
Argenziano G, Cerroni L, Zalaudek I, et al. Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol. 2012;67(1):54-59. PubMed CrossRef
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