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The skin and nevi pigmentation during pregnancy
The positive impact of providing information from a computer-aided multispectral digital skin lesion analysis system on melanoma biopsy sensitivity
(Poster reference number 4834)
Darrell Rigel, MD, MS, New York University School of Medicine, New York, NY, United States; Clay Cockerell, MD, University of Texas Southwestern Medical Center, Dallas, TX, United States; Jane Yoo, MD, MPH, Albert Einstein College of Medicine, Bronx, NY, United States; June Robinson, MD, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Mrinalini Roy, MelaSciences, Irvington, NY, United States; Richard White, IRIS Interactive Horizons, Cody, WY, United States Background: Diagnosing melanocytic skin lesions has traditionally relied on a variety of techniques including clinical examination and dermoscopy. Computer analysis has augmented this process. Objective: To determine the impact on diagnostic performance for melanoma biopsy sensitivity of dermatologists with varying degrees of experience and training when given the information from a multispectral digital skin lesion analysis (MSDSLA) system. Methods: 24 pigmented lesions were chosen that had been analyzed as part of a prior study by a MSDSLA system (5 melanomas and 19 other pigmented lesions). 4 lesions were not evaluable by the MSDSLA system but were included to determine the impact of receiving this type of information on the biopsy decision. The lesions were grouped into 4 composite patients of 6 lesions each with matching actual historic and clinical characteristics. 179 clinical dermatologists attending the 2011 Winter Clinical Dermatology Conference-Hawaii were presented these patients thru viewing distant, close-up and dermoscopic color images. For each lesion, information was provided regarding patient sex, age, and anatomic site, size of lesion and pertinent history. Each participant was asked ‘‘Would you biopsy this lesion?’’ They were then given the information provided by the MSDSLA system and again asked ‘‘Would you biopsy this lesion?’’ and responded through an electronic keypad. Individual responses before and after MSDSLA information receipt were compared to determine the impact the device had on lesion management. Results: Availability of the MSDSLA information improved the average biopsy sensitivity of the dermatologists for the 5 melanomas from 65% prior to receiving the MSDSLA information to 93% after receiving the information (P \.001). Biopsy specificity went from 52% pre to 38% post information receipt. Biopsy rates of lesions that were MSDSLA negative fell from 43% pre- to 25% postinformation (P \ .01). Of the 4 lesions that were not evaluable by the MSDSLA system, biopsy rates went from 37% pre and rose only slightly post information (to 42% P ¼ NS) showing neither a positive or negative effect when the system provided no additional information.
White shiny structures: Morphologic evaluation under polarized dermoscopy
(Poster reference number 4582)
Tracey Liebman, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Ashfaq Marghoob, MD, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Harold Rabinovitz, MD, Skin and Cancer Associates, Plantation, FL, United States; Stephen Dusza, MPH, Memorial Sloan-Kettering Cancer Center, New York, NY, United States Background: White shiny structures, which include white shiny lines, white shiny areas, and rosettes, are dermoscopic features solely observed under polarized dermoscopy (PD). Objective: To evaluate the prevalence of the varied morphologies of white shiny structures in melanoma, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), actinic keratosis (AK), and lichen planuselike keratosis (LPLK). Methods: Retrospective study using polarized dermoscopic images of biopsy-proven melanoma, BCC, SCC, AK, and LPLK. Results: 538 lesions were evaluated under PD. One or more types of white shiny structures were observed in 39% (208/538) of study lesions. BCCs were significantly more likely to exhibit a combination of white shiny areas and white shiny lines (short lines and/or ill-defined strands) (31.9%; 61/191) when compared to other lesion types (P \.001). BCCs were also significantly more likely to have white shiny lines distributed without any organized pattern when compared to other lesion types (P \.001). Lines in melanoma were significantly more likely than other lesion types to be oriented in an orthogonal distribution (P\.001). When white shiny lines were present (33.1%; 51/154), melanomas were significantly more likely than other lesions (P \.001) to exhibit short discrete white lines rather than ill-defined strands. Rosettes were significantly more likely to be observed in actinic tumors (32.6%; 46/141) than other lesion types (P \.001). Conclusion: The presence of white shiny lines of any length along with white shiny areas is most suggestive of a diagnosis of BCC (P \.001). Melanomas are more likely to exhibit short white shiny lines in an orthogonal distribution (P\.001) and without white shiny areas. Actinic tumors are most likely to display rosettes (P \.001). Commercial support: None identified.
Conclusion: Computerized image analysis using a MSDSLA system has the potential to improve management of potentially dangerous pigmented skin lesions by significantly enhancing sensitivity in detecting lesions requiring biopsy and removal and in reducing unnecessary biopsies. Commercial support: This study was supported in part by MelaSciences.
NONMELANOMA SKIN CANCER
The skin and nevi pigmentation during pregnancy
(Poster reference number 4619)
Alin Laurentiu Tatu, MD, PhD, Faculty of Medicine, University Dunarea de Jos, Galati, Romania Objectives: Linea alba, areolas and genital mucosa becomes hyperpigmented during pregnancy. Do nevi change color also? I studied the relationship between localization, sun exposure, and color of nevi related to pregnancy.
A case of a malignant proliferating trichilemmal tumor with perineural invasion
(Poster reference number 5252)
Oliver Wisco, DO, Mystic Valley Dermatology, Stoneham, MA, United States; Donald Grande, MD, Mystic Valley Dermatology, Stoneham, MA, United States; Krista Reis, PA, Mystic Valley Dermatology, Stoneham, MA, United States; Miriam O’Leary, MD, Tufts Medical Center, Boston, MA, United States
Conclusions: 31.8% of nevi from nondistended areas are hyperpigmented during pregnancy. 18.19% of those from not sun exposed areas decreased pigmentation six months postpartum and 13.61% from sun exposed areas are stable. 59% of nevi from distended areas are hypopigmented in pregnancy and 40.9% of them increased pigmentation at 6 months postpartum. In pregnancy, the nevic hyperpigmentation is associated with the pigmentation of linea alba, areolas and genital area.
A scalp cyst excision is a common procedure performed by a dermatologist that is rarely considered outside of the realm of routine practice. However, occasionally the preoperative diagnosis is incorrect and an aggressive malignant tumor is found. We present a unique case of an 85 year-old male with a malignant proliferating trichilemmal tumor with perineural invasion on the occipital scalp. The patient presented with a 5.0 cm 3 4.0 cm presumed cyst on the occipital scalp to our dermatologic surgical unit for routine excision. The tumor had been slowly growing the past several years and other than mild tenderness, the lesion was essentially asymptomatic. Suspicion arose for malignant change during the procedure due to the extensive hemostasis required. The pathology review revealed a malignant proliferating trichilemmal tumor with perineural invasion. Based on this report and a discussion at the local university hospital tumor board, the patient was referred to the ENT surgical oncologist and a wide local excision was performed followed by postoperative radiation. Malignant proliferating trichilemmal tumors are rare, with scant information in the literature of tumors with perineural invasion. This case highlights the potential aggressiveness of a tumor that can be easily misdiagnosed clinically and should be considered by both the clinician and the pathologist to ensure appropriate treatment. Potential indicators of malignant change of a trichilemmal cyst include a larger than normal size and extensive bleeding during the procedure.
Commercial support: None identified.
Commercial support: None identified.
Method: I followed up 420 pregnant patients and 1642 nevi that changed color: from distended, not distended sun exposed and not distended, not sun exposed areas. Results: 73.57% of pregnant patients had hyperpigmentation of areolas, linea alba and genital mucosa during pregnancy 93.2% of them decreased pigmentation of linea alba and genital mucosa six months postpartum 64% of pregnant patients with areola hyperpigmentation are stable 6 months postpartum 13 nevi from distended areas diminished color in third trimester and the color comes back after pregnancy; from 6 nevi of nondistended non sun exposed areas 4 are hyperpigmented in the third trimester and are coming back at baseline; 3 nevi from nondistended and sun exposed areas are hyperpigmented in the third trimester and are stable after pregnancy.
AB148
J AM ACAD DERMATOL
APRIL 2012
(Poster reference number 4834)
Darrell Rigel, MD, MS, New York University School of Medicine, New York, NY, United States; Clay Cockerell, MD, University of Texas Southwestern Medical Center, Dallas, TX, United States; Jane Yoo, MD, MPH, Albert Einstein College of Medicine, Bronx, NY, United States; June Robinson, MD, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Mrinalini Roy, MelaSciences, Irvington, NY, United States; Richard White, IRIS Interactive Horizons, Cody, WY, United States Background: Diagnosing melanocytic skin lesions has traditionally relied on a variety of techniques including clinical examination and dermoscopy. Computer analysis has augmented this process. Objective: To determine the impact on diagnostic performance for melanoma biopsy sensitivity of dermatologists with varying degrees of experience and training when given the information from a multispectral digital skin lesion analysis (MSDSLA) system. Methods: 24 pigmented lesions were chosen that had been analyzed as part of a prior study by a MSDSLA system (5 melanomas and 19 other pigmented lesions). 4 lesions were not evaluable by the MSDSLA system but were included to determine the impact of receiving this type of information on the biopsy decision. The lesions were grouped into 4 composite patients of 6 lesions each with matching actual historic and clinical characteristics. 179 clinical dermatologists attending the 2011 Winter Clinical Dermatology Conference-Hawaii were presented these patients thru viewing distant, close-up and dermoscopic color images. For each lesion, information was provided regarding patient sex, age, and anatomic site, size of lesion and pertinent history. Each participant was asked ‘‘Would you biopsy this lesion?’’ They were then given the information provided by the MSDSLA system and again asked ‘‘Would you biopsy this lesion?’’ and responded through an electronic keypad. Individual responses before and after MSDSLA information receipt were compared to determine the impact the device had on lesion management. Results: Availability of the MSDSLA information improved the average biopsy sensitivity of the dermatologists for the 5 melanomas from 65% prior to receiving the MSDSLA information to 93% after receiving the information (P \.001). Biopsy specificity went from 52% pre to 38% post information receipt. Biopsy rates of lesions that were MSDSLA negative fell from 43% pre- to 25% postinformation (P \ .01). Of the 4 lesions that were not evaluable by the MSDSLA system, biopsy rates went from 37% pre and rose only slightly post information (to 42% P ¼ NS) showing neither a positive or negative effect when the system provided no additional information.
White shiny structures: Morphologic evaluation under polarized dermoscopy
(Poster reference number 4582)
Tracey Liebman, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Ashfaq Marghoob, MD, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Harold Rabinovitz, MD, Skin and Cancer Associates, Plantation, FL, United States; Stephen Dusza, MPH, Memorial Sloan-Kettering Cancer Center, New York, NY, United States Background: White shiny structures, which include white shiny lines, white shiny areas, and rosettes, are dermoscopic features solely observed under polarized dermoscopy (PD). Objective: To evaluate the prevalence of the varied morphologies of white shiny structures in melanoma, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), actinic keratosis (AK), and lichen planuselike keratosis (LPLK). Methods: Retrospective study using polarized dermoscopic images of biopsy-proven melanoma, BCC, SCC, AK, and LPLK. Results: 538 lesions were evaluated under PD. One or more types of white shiny structures were observed in 39% (208/538) of study lesions. BCCs were significantly more likely to exhibit a combination of white shiny areas and white shiny lines (short lines and/or ill-defined strands) (31.9%; 61/191) when compared to other lesion types (P \.001). BCCs were also significantly more likely to have white shiny lines distributed without any organized pattern when compared to other lesion types (P \.001). Lines in melanoma were significantly more likely than other lesion types to be oriented in an orthogonal distribution (P\.001). When white shiny lines were present (33.1%; 51/154), melanomas were significantly more likely than other lesions (P \.001) to exhibit short discrete white lines rather than ill-defined strands. Rosettes were significantly more likely to be observed in actinic tumors (32.6%; 46/141) than other lesion types (P \.001). Conclusion: The presence of white shiny lines of any length along with white shiny areas is most suggestive of a diagnosis of BCC (P \.001). Melanomas are more likely to exhibit short white shiny lines in an orthogonal distribution (P\.001) and without white shiny areas. Actinic tumors are most likely to display rosettes (P \.001). Commercial support: None identified.
Conclusion: Computerized image analysis using a MSDSLA system has the potential to improve management of potentially dangerous pigmented skin lesions by significantly enhancing sensitivity in detecting lesions requiring biopsy and removal and in reducing unnecessary biopsies. Commercial support: This study was supported in part by MelaSciences.
NONMELANOMA SKIN CANCER
The skin and nevi pigmentation during pregnancy
(Poster reference number 4619)
Alin Laurentiu Tatu, MD, PhD, Faculty of Medicine, University Dunarea de Jos, Galati, Romania Objectives: Linea alba, areolas and genital mucosa becomes hyperpigmented during pregnancy. Do nevi change color also? I studied the relationship between localization, sun exposure, and color of nevi related to pregnancy.
A case of a malignant proliferating trichilemmal tumor with perineural invasion
(Poster reference number 5252)
Oliver Wisco, DO, Mystic Valley Dermatology, Stoneham, MA, United States; Donald Grande, MD, Mystic Valley Dermatology, Stoneham, MA, United States; Krista Reis, PA, Mystic Valley Dermatology, Stoneham, MA, United States; Miriam O’Leary, MD, Tufts Medical Center, Boston, MA, United States
Conclusions: 31.8% of nevi from nondistended areas are hyperpigmented during pregnancy. 18.19% of those from not sun exposed areas decreased pigmentation six months postpartum and 13.61% from sun exposed areas are stable. 59% of nevi from distended areas are hypopigmented in pregnancy and 40.9% of them increased pigmentation at 6 months postpartum. In pregnancy, the nevic hyperpigmentation is associated with the pigmentation of linea alba, areolas and genital area.
A scalp cyst excision is a common procedure performed by a dermatologist that is rarely considered outside of the realm of routine practice. However, occasionally the preoperative diagnosis is incorrect and an aggressive malignant tumor is found. We present a unique case of an 85 year-old male with a malignant proliferating trichilemmal tumor with perineural invasion on the occipital scalp. The patient presented with a 5.0 cm 3 4.0 cm presumed cyst on the occipital scalp to our dermatologic surgical unit for routine excision. The tumor had been slowly growing the past several years and other than mild tenderness, the lesion was essentially asymptomatic. Suspicion arose for malignant change during the procedure due to the extensive hemostasis required. The pathology review revealed a malignant proliferating trichilemmal tumor with perineural invasion. Based on this report and a discussion at the local university hospital tumor board, the patient was referred to the ENT surgical oncologist and a wide local excision was performed followed by postoperative radiation. Malignant proliferating trichilemmal tumors are rare, with scant information in the literature of tumors with perineural invasion. This case highlights the potential aggressiveness of a tumor that can be easily misdiagnosed clinically and should be considered by both the clinician and the pathologist to ensure appropriate treatment. Potential indicators of malignant change of a trichilemmal cyst include a larger than normal size and extensive bleeding during the procedure.
Commercial support: None identified.
Commercial support: None identified.
Method: I followed up 420 pregnant patients and 1642 nevi that changed color: from distended, not distended sun exposed and not distended, not sun exposed areas. Results: 73.57% of pregnant patients had hyperpigmentation of areolas, linea alba and genital mucosa during pregnancy 93.2% of them decreased pigmentation of linea alba and genital mucosa six months postpartum 64% of pregnant patients with areola hyperpigmentation are stable 6 months postpartum 13 nevi from distended areas diminished color in third trimester and the color comes back after pregnancy; from 6 nevi of nondistended non sun exposed areas 4 are hyperpigmented in the third trimester and are coming back at baseline; 3 nevi from nondistended and sun exposed areas are hyperpigmented in the third trimester and are stable after pregnancy.
AB148
J AM ACAD DERMATOL
APRIL 2012