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Revised 3-Step Dermoscopic Algorithm for the Management Of CORRESPONDENCE Figures 1 and 2. A total of 17 lesions exhibited the PRP, RESEARCH LETTERS and all 17 of these lesions were histopathologically di- agnosed as acral melanoma. In both algorithms, the same 26 lesions were catego- rized into the group not showing typical benign dermo- Revised 3-Step Dermoscopic scopic patterns and larger than 7 mm in diameter. Bi- Algorithm for the Management opsy was performed in 19 of the 26 lesions, and the of Acral Melanocytic Lesions cral volar skin is the most prevalent site of ma- 191 (166 + 25) Acquired melanocytic lignant melanoma in nonwhite populations. In lesions on acral volar skin A 2007, our group proposed a 3-step algorithm for the management of acquired melanocytic lesions affect- 174 (166 + 8) Nonparallel 17 (0 + 17) Parallel 1 First step ing acral volar skin (Figure 1). We now know that al- ridge pattern ridge pattern most all acral melanomas arise de novo, not in associa- tion with a preexisting acral nevus.2 Given that an acral 115 (115 + 0) Diameter 59 (51 + 8) Diameter nevus has virtually no risk of developing to acral mela- Second step noma, follow-up of a definitely diagnosed acral nevus is ≤7 mm >7 mm not necessary. Taking this point into account, we have revised the 3-step algorithm. In the revised algorithm, 33 (33 + 0) Typical PFP, 26 (18 + 8) Dermoscopic the order of the second and the third steps in the previ- Third step LLP, or regular fibrillar features not conforming ous algorithm is reversed, and a new category without pattern to the left box need of further follow-up is introduced. 148 (148 + 0) Follow-up 43 (18 + 25) Biopsy for histopathologic evaluation Methods. We retrospectively applied the original and the revised algorithms to consecutive case series of acquired melanocytic lesions on acral volar skin first seen from Janu- Figure 1. Original 3-step algorithm1 for the management of acquired acral ary 2005 through December 2008. Congenital pigmented melanocytic lesions. The numbers indicate numbers of lesions (nonmelanoma or follow-upϩmelanoma). PFP indicates parallel furrow lesions, drug-induced pigmentation, volar melanotic mac- pattern; LLP, latticelike pattern. ules, Peutz-Jeghers syndrome, and hemorrhage were ex- cluded. Biopsied lesions were histopathologically evalu- ated by expert dermatopathologists. 191 (166 + 25) Acquired melanocytic The revised 3-step dermoscopic algorithm (Figure 2) lesions on acral volar skin proceeds as follows: in the first step, if a lesion shows the parallel ridge pattern (PRP), we biopsy it regardless of the size. If the lesion does not show the PRP, we pro- 174 (166 + 8) Nonparallel 17 (0 + 17) Parallel First step ceed to the second step in which we check whether it ridge pattern ridge pattern shows any of the typical dermoscopic patterns of be- nign acral nevus on the whole area of the lesion (typical 101 (101 + 0) Typical PFP, 73 (65 + 8) Dermoscopic parallel furrow pattern, typical latticelike pattern, or regu- Second step LLP, or regular fibrillar features not conforming lar fibrillar pattern). If the lesion shows these typical be- pattern to the left box nign patterns, there is no need of further follow-up. How- ever, if the lesion does not show any of these typical dermoscopic patterns, we proceed to step 3, in which we 47 (47 + 0) 26 (18 + 8) Third step Diameter Diameter measure the maximum diameter. If the lesion is more than ≤7 mm >7 mm 7 mm in maximum diameter, we recommend biopsy for histopathologic evaluation (Figure 3). If the lesion is 101 (101 + 0) No 47 (47 + 0) 43 (18 + 25) Biopsy for follow-up Follow-up histopathologic smaller than 7 mm in diameter, we recommend peri- evaluation odic clinical and dermoscopic follow-up. Results. A total of 191 acquired acral melanocytic le- Figure 2. Revised 3-step algorithm. The order of the second and the third sions collected from 176 Japanese patients were en- steps in the original algorithm is reversed, and a new category without need of further follow-up is introduced. The numbers indicate numbers of lesions rolled. Numbers of lesions classified into each category (nonmelanoma or follow-upϩmelanoma). PFP indicates parallel furrow of the original and revised algorithms are shown in pattern; LLP, latticelike pattern. ARCH DERMATOL/ VOL 147 (NO. 6), JUNE 2011 WWW.ARCHDERMATOL.COM 741 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 low-up is not necessary for definitively diagnosed ac- quired acral melanocytic nevus because it carries no risk of development to melanoma. By using the revised algorithm, physicians can substan- tially reduce the number of lesions that need follow-up with- out missing early acral melanoma. We advise most pa- tients in the follow-up category to visit us once or twice a year, though there is no evidence to specify adequate fre- quency of follow-up. Furthermore, we ask them to come back soon if the lesion enlarges to more than 7 mm. In this revised 3-step algorithm, the most confusing point may be evaluation in the second step. Accurate iden- tification of the typical dermoscopic patterns is essen- tial in this step. To avoid missing early acral melano- mas, if a lesion does not show stereotypical benign patterns, it should be classified into the category not con- forming to the typical benign patterns. Another possible problem in using this algorithm is differentiation between acquired and congenital acral nevi because the algorithm is designed only for Figure 3. Dermoscopic image of an acral melanocytic lesion not conforming acquired melanocytic lesions. Our group has recently to any of the typical parallel furrow, latticelike, or regular fibrillar patterns. In reported dermoscopic patterns characteristic of congen- this irregular fibrillar pattern, the starting or ending points of fibrils are not 8 arranged on the lines corresponding to the furrows of the skin markings. In ital acral melanocytic nevi, which will help identify addition, overall pigment distribution is irregular and asymmetric. The size of and exclude congenital acral nevi. However, it may be this brownish macule was 9.5ϫ7.4 mm, and biopsy specimens were taken impossible for us to identify all the congenital acral nevi and analyzed. Histopathologically, it was diagnosed as melanoma in situ. as such. Therefore, some congenital acral nevi are possi- bly evaluated with this revised 3-step algorithm. We remaining 7 lesions were not biopsied because of re- believe that this does not cause a serious problem fusal by patients or physically or psychologically com- because the number of congenital acral nevi, particu- plicated conditions of the patients. Of the biopsied 19 larly those classified into the category to be biopsied, lesions, 8 lesions were histopathologically diagnosed as may be very small. acral melanoma, In the original algorithm, 148 lesions In conclusion, we believe that the revised 3-step al- were categorized into the group to be followed up. In con- gorithm greatly aids clinicians in efficiently managing ac- trast, in the revised algorithm, 101 lesions of the 148 le- quired melanocytic lesions on acral volar skin. sions (68.2%) were categorized into the group without need of further follow-up, and the remaining 47 lesions Hiroshi Koga, MD (31.8%) were categorized into the group to be followed Toshiaki Saida, MD, PhD up periodically. In actuality, biopsy was performed in 28 of the 148 lesions categorized into the follow-up group Author Affiliations: Clinical Trial Research Center, Shin- in the original algorithm, and all of them were melano- shu University Hospital, Matsumoto, Japan (Dr Koga); cytic nevi. The remaining 120 lesions were followed up Department of Dermatology, Shinshu University School for a median of 48 months (approximate follow-up range, of Medicine, Matsumoto (Dr Saida). 21-68 months). No significant changes in dermoscopic Correspondence: Dr Koga, Clinical Trial Research Cen- features were observed in any of these 120 lesions dur- ter, Shinshu University Hospital, 3-1-1 Asahi, Matsu- ing the follow-up period. moto 390-8621, Japan ([email protected]). Author Contributions: Both authors had full access to Comment. In the original 3-step algorithm for the man- all of the data in the study and take responsibility for the agement of acquired acral melanocytic lesions, criteria integrity of the data and the accuracy of the data analy- for biopsy were clearly established, but all the other le- sis. Study concept and design: Koga and Saida. Acquisi- sions were categorized into the group to be followed up. tion of data: Koga. Analysis and interpretation of data: Koga The relationship between acquired melanocytic nevi and and Saida. Drafting of the manuscript: Koga and Saida. Criti- malignant melanoma is still controversial. However, if cal revision of the manuscript for important intellectual con- limited only to acral melanoma, morphologic and mo- tent: Koga and Saida. Study supervision: Saida. lecular findings support de novo development without Financial Disclosure: None reported. preexisting nevus.3,4 Dermoscopically, the typical pat- 1. Saida T, Koga H. Dermoscopic patterns of acral melanocytic nevi: their varia- tern of early acral melanoma is the PRP, whereas that of tions, changes, and significance. Arch Dermatol. 2007;143(11):1423-1426. acral nevus is the parallel furrow pattern or its variants.5 2. Saida T. Lessons learned from studies of the development of early melanoma. Int J Clin Oncol. 2005;10(6):371-374. Although some temporal changes in dermoscopic fea- 3. Bastian BC, Kashani-Sabet M, Hamm H, et al. Gene amplifications character- tures are detected in acral nevi, transition from the be- ize acral melanoma and permit the detection of occult tumor cells in the sur- nign dermoscopic patterns to the PRP has been never ob- rounding skin.
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