Digital Epiluminescence Microscopy Monitoring of High-Risk Patients

STUDY Digital Epiluminescence Microscopy Monitoring of High-Risk Patients

June K. Robinson, MD; Brian J. Nickoloff, MD, PhD

Objective: To examine the outcome of digital epilumi- dence in and comfort with dermatologic surveillance and nescence microscopic (DELM) surveillance of atypical skin self-examination performance were assessed. nevi in a high-risk population for 4 years. Results: During annual surveillance with DELM, 5.5% of Design: Atypical, flat melanocytic lesions in 100 pa- the lesions changed. Among the 193 excisional biopsy speci- tients at high risk of developing melanoma were fol- mens there were 4 melanomas in situ, 169 dysplastic nevi, lowed annually with DELM. Pigmentary changes or an and 20 common nevi. Confidence in and comfort with sur- increase in DELM diameter of 1 mm or greater was an veillance and skin self-examination improved after DELM. indication to perform an excisional biopsy. Conclusions: The criteria applied to detect substantial Setting: Cardinal Bernardin Cancer Center Melanoma DELM changes were an increase in DELM diameter of 1 Program, Loyola University Health System, Maywood. mm or greater and pigmentary changes, including radial streaming, focal enlargement, peripheral black dots, Patients: A consecutive sample of 3482 lesions from 100 and “clumping” within the irregular pigment network. patients (aged 18-65 years) with at least 2 images of the Use of DELM enhanced confidence in and comfort with same lesion. care, which extended to performing more extensive skin self-examination. Main Outcome Measures: The DELM change was con- firmed by histopathologic examination. Patient confi- Arch Dermatol. 2004;140:49-56

LTHOUGH EXPERIENCED Dermatologists use total cutaneous dermatologists diagnose photographs to monitor patients for new most melanomas with the lesions and changes in atypical nevi.1,18 unaided eye, epilumines- Digital ELM (DELM) (digital dermos- cence microscopy (ELM) copy), which archives images of nevi, sup- enhancesA the diagnostic accuracy of early ports surveillance of atypical nevi with 30- cases and helps select pigmented lesions fold magnification of pigmentary structural that require biopsy.1-5 Most dermatolo- components.19,20 Digital ELM assists in gists agree that patients with atypical or short-term digital monitoring of suspi- dysplastic nevi are at increased risk of de- cious nevi (which are followed for 3 veloping melanoma,6 and they follow up months, and those with changes are ex- patients with total cutaneous examina- cised21) and long-term surveillance of tion either annually or every 4 to 6 months. nevi.22-26 We report our experience with Since dysplastic nevi either are precur- a population with multiple atypical nevi sors to melanoma7-13 or identify persons followed annually with DELM using de- From the Department of at risk of developing melanoma,14-16 in- fined criteria of change for biopsy of nevi. Medicine, Division of tense surveillance of atypical nevi and new Dermatology (Dr Robinson), pigmented lesions is performed so that and Department of Pathology melanomas can be found and removed in METHODS (Drs Robinson and Nickoloff), the early curable phase. For people with Cardinal Bernardin Cancer dysplastic nevi, the risk of developing GENERAL CHARACTERISTICS Center, Loyola University OF THE POPULATION Stritch School of Medicine, melanoma increases with a personal his- Maywood, Ill. The authors have tory of melanoma, and each first-degree Between January 1, 1998, and December 31, no relevant financial interest in relative with melanoma confers risk (eg, 2002, 100 patients underwent baseline DELM this article. 1 first-degree relative: relative risk=4).16,17 and annual imaging of atypical nevi. A derma-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 tologist (J.K.R.) evaluated the patients clinically 6 months af- metry of the shape of the lesion, asymmetry of the pigmentary ter DELM imaging sessions. Clinical inclusion criteria for DELM pattern, and the appearance of structural ELM changes such were 50 or more melanocytic nevi27 with at least 1 nevus mea- as irregularly distributed black dots in the periphery, radial suring 8 mm or more in diameter, a personal or family history streaming, whitish veil, gray-blue area, pseudopods, the ap- of a melanoma in a first- or second-degree relative, and at least pearance of “clumping” or broadening of the prominent ir- 3 clinically atypical nevi with 3 of the ABCD criteria found in regular or nonuniform pigment network, and a change in the melanoma: asymmetry, color variation over the surface of the scarlike depigmentation.25,31 The criteria used for excisional bi- nevus (irregular pigmentation), and hazy or irregular bor- opsy are those of Kittler et al,25 with the addition of clumping ders.28 The patients were at least 18 years old when baseline or broadening of the prominent irregular pigment network and DELM was performed. The pathology reports of nevi and mela- an increase of 1 mm or more in DELM diameter compared with nomas removed before entry into the study were reviewed. The previous images. pathological specimens of those with a history of melanoma Since the pressure of applying the instrument to the skin were reviewed. Patients entered into the study had at least 3 may produce minor variations in diameter, symmetrical en- mild, moderate, or severely dysplastic melanocytic nevi with largement less than 1 mm was not a criterion for biopsy. When architectural disorder.29,30 The numbers and locations of dys- the nevus was located in an anatomic area undergoing a rapid plastic nevi, melanomas in situ, and invasive melanomas were increase in size, for example, the abdomen in pregnant women, recorded. an increasing diameter was not sufficient to warrant biopsy. Patients were informed of their increased risk of develop- Overall pigmentation change in many nevi consistent with pig- ing melanoma and that they could develop new melanocytic nevi mentary change in the surrounding skin from seasonal solar throughout their lives. During the initial DELM session, as- exposure was not an indication to perform a biopsy. A de- pects of the lesions with the ABCD criteria were demonstrated crease in brown globules and disappearance of black dots were using their DELM images. Patients were encouraged to perform not changes that prompted biopsy of the lesion. monthly skin self-examination (SSE) and to compare their nevi Standard histologic examination of serial step sections was with baseline photographs when they were available. performed on all excised lesions. The histopathologic diagnosis of dysplastic nevi and early melanoma was based on estab- 29,30 DELM TECHNIQUE lished architectural and cellular criteria.

The total-body and individual images of patients’ multiple clini- CONFIDENCE IN AND COMFORT cally atypical nevi and common nevi were examined and elec- WITH SURVEILLANCE METHODS tronically stored using a DELM imaging system (MoleMax II; Derma Instruments, Vienna, Austria). The system offers a maxi- Before and after the first year of DELM surveillance, patients mum field of view of 1 cm with 30-fold magnification. Mela- completed a brief survey using a 5-point scale to define their nocytic skin lesions with a maximum diameter exceeding the confidence in the dermatologist and their comfort with being field of view of the electronic camera were not included in this monitored by visual examination, photographic comparison, study. Digital ELM images were stored without compression and DELM. Additional questions used a 5-point scale to de- in bitmap format. The pixel resolution of each image was fine their confidence in and comfort with performing monthly 640ϫ480 at 24-bit color depth. SSE and performance of SSE before and after having DELM and For atypical flat or only slightly raised nevi without a his- using photographs for SSE. Patients provided their opinion of tory of change or surface microscopic evidence of melanoma the advantages and disadvantages of DELM. Data are given as with a diameter of 3 mm to 1 cm, the entire surface was en- mean (SD) unless otherwise specified. compassed by the DELM system. Nevi on contoured surfaces, for example, the ear, were compressed with the DELM unit. If it was not possible to adequately flatten the area, the image was RESULTS not obtained. Lesions meeting melanoma-specific criteria were not entered into the study to be followed for change over time because they were surgically removed before entry into the study. GENERAL CHARACTERISTICS Atypical nevi had 1 or 2 of the following ELM features de- scribed by Kittler et al25,26: an irregular or nonuniform pig- The study population of 100 patients (mean age, 38.4 ment network, irregular overall pigmentation, asymmetry of years; 72% women) included 81 with a personal history color or contour along 1 axis, central black dots, radial stream- 26-28 of melanoma in situ or invasive melanoma (Table 1). ing, and scarlike depigmentation. All clinically atypical nevi During the 4-year period, 1532 melanocytic skin le- 3 mm or more in diameter and selected common nevi greater than 5 mm in diameter were electronically archived. One der- sions had at least 3 sequentially recorded images and 1950 matologist (J.K.R.) examined all patients and imaged nevi with had 2 recorded images by DELM. At the annual fol- a low level of clinical suspicion; therefore, biopsy was not per- low-up examination, 215 new nevi greater than 3 mm formed at the first visit. in diameter were added to the patients’ total images and At the annual examination, nevi were examined by DELM have only 1 recorded image. Thus, during the 4-year pe- and the images were stored. New nevi greater than 3 mm in di- riod, a total sample of 3697 nevi had images stored, with ameter were added to the patient’s total images. The dermatolo- 3482 having 2 or more images. Nevi were compared with gist performed online side-by-side comparison of DELM im- baseline images in side-by-side comparison and stored ages at each follow-up visit of the respective patient for each lesion in years 1 and 2. If there was no change in the nevus in on file and made clinical decisions about performing a biopsy. study years 3 and 4, then the image was not stored. The EXCISIONAL BIOPSY median number of lesions evaluated and stored sequentially for 3 or more years was 15 per patient (range, 2-35). Criteria for excisional biopsy of nevi followed by DELM were The median total follow-up interval was 36.2 months morphologic changes of regression, color change with the ap- (range, 12-48 months). Eighty percent of all follow-up pearance of new colors, enlargement along 1 axis causing asym- intervals ranged from 24 to 36 months.

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 PATHOLOGY OF ELM FEATURES Table 1. Characteristics of 100 Patients at High Risk In the 4 years of surveillance, 193 excisional biopsies were of Developing Melanoma performed in 55 patients (mean age, 32.8 years; 60% wom- Patients, No. en) (Table 2). The pathological findings showed no invasive melanomas, 4 melanomas in situ in 4 individu- Characteristic Women Men als, 169 dysplastic nevi in 37 individuals, and 20 benign Ն3 Pathologically dysplastic nevi and Ն50 nevi 72 28 nevi in 14 individuals (Table 2) (Figures 1, 2, and 3). and Median follow-up for excised lesions was 12.3 months Personal history of melanoma (range, 3.0-32.5 months). Melanoma in situ 21 2 Յ One of the discriminatory features of melanoma, Melanoma 1.0 mm 35 19 Melanoma Ͼ1.0 mm 0 4 radial streaming, was found in a melanoma in situ that Total 56 25 changed in 1 year (Figure 1). This case also illustrates or clumping or broadening of the prominent irregular or Family history of melanoma in 1 first-degree 12 3 nonuniform pigment network seen in the initial lesion. relative This clumping of the prominent irregular pigment net- Family history of melanoma in Ն2 first-degree 40 work was noted in another melanoma in situ. The in- relatives traepidermal nests of severely atypical melanocytes seen in the serial section (Figure 1D) correspond to the radial streaming at the 6-o’clock position of the DELM Focal or symmetrical enlargement occurred in 95% image of the lesion (Figure 1C) and of the specimen, of the dysplastic nevi and in 100% of the melanomas in which was grossed and inked to orient the 6-o’clock situ (Table 3). Change is symmetrical when the lesion margin. enlarges symmetrically even if the lesion was asymmetri- Another significant pigmentary feature of mela- cal at the time of presentation. Pigmentary structural fea- noma is peripheral black dots. One patient had a single tures associated with melanoma in situ are radial stream- black dot appear at the periphery of the atypical nevus ing, pseudopods (focal enlargement), peripheral black (Figure 2C, black dot at 2 o’clock). The pathological sec- dots, and clumping within the irregular pigment net- tion through the black dot shows nests of cells with mod- work. Regression was not seen in any of the lesions fol- erate atypia at the tips of the rete ridges (Figure 2F). Dur- lowed in this study. The remaining melanocytic lesions ing the first trimester of pregnancy (14 months after (87.4%) were stable over time or had overall darker or baseline imaging), focal enlargement developed in 1 di- lighter appearance associated with pigmentary change in mension (change in shape), and the irregular pigment the surrounding skin. network became more prominent. Although this case has a more prominent irregular pigment network, it does not CONFIDENCE IN AND COMFORT have the dense central clumped pigmentation seen in the WITH SURVEILLANCE METHODS DELM of melanoma in situ of the case shown in Figure AND PERFORMANCE OF SSE 1. The clinical photograph of the lesion shows a single darker area consistent with the peripheral black dot and Patients had a greater degree of confidence in and more the irregular pigment network. comfort with their surveillance by DELM than with vi- The final significant DELM feature, focal enlarge- sual examination or photographs before DELM (paired ment, can be seen in atypical nevi and melanoma. In the samples test, PϽ.001) (Table 4). Confidence in and com- case of a mildly dysplastic compound nevus, there was fort with performing SSE improved after DELM for those focal enlargement in 1 dimension 1 year after the initial using visual SSE and those with photographs. Those with image was acquired (Figure 3B). photographs practiced the most extensive SSE after DELM During this study, 3482 nevi were monitored for at (Table 5). The advantages of DELM were fewer scars least 12 months, and 193 underwent biopsy for change. from biopsies and peace of mind; the disadvantage was Thus, 5.5% of the pigmented lesions demonstrated the amount of time it took to perform DELM. changes on DELM and were excised. There were no significant differences in the rate of biopsy among the 3 COMMENT categories of risk: personal history of melanoma (median, 2.0; range, 0-5), family history of melanoma in 1 Patients with multiple atypical nevi may have many, first-degree relative (median, 2.0; range, 0-6), and fam- sometimes hundreds, of clinically abnormal–appearing ily history of melanoma in 2 or more first-degree rela- nevi. Surveillance of these nevi is complicated by the tives (median, 1.0; range, 0-2) (Kruskal-Wallis test, multiplicity of atypical nevi. The differentiation of P=.20) (Table 2). atypical nevi from early melanomas is especially chal- The median diameter of the excised lesions was 4.3 lenging for small-diameter lesions (3-6 mm in mm (range, 3.3-6.2 mm). There is a significant differ- diameter). This study of 100 individuals demonstrates a ence in the diameter of the 3 types of excised pigmented 5.5% rate of change in the 3482 nevi followed annually. lesions (Kruskal-Wallis test, PϽ.001) (Table 2). Biop- In a study of a European population by Kittler et al,25 74 sies are performed of melanomas in situ and dysplastic (4%) of 1862 sequentially recorded nevi demonstrated nevi with smaller diameters than those of common nevi changes requiring biopsy. Despite different populations (Wilcoxon signed rank test, PϽ.001). and slightly different entry criteria, the 2 studies dem-

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Melanomas Dysplastic Common Characteristic Biopsies, No. In Situ, No. Nevi, No. Nevi, No. Ն3 Histologically dysplastic nevi and Ն50 nevi (n = 100) 193 4 169 20 and Personal history of melanoma in situ or invasive melanoma (n = 81) 155 1 142 12 or Family history of melanoma in 1 first-degree relative (n = 15) 34 1 25 8 Family history of melanoma in Ն2 first-degree relatives (n = 4) 4 2 2 0 Diameter, median (range), mm (single greatest dimension) 4.3 (3.3-6.2) 4.2 (3.8-4.6)* 4.3 (3.3-6.5)* 5.1 (4.1-6.2)*

*The difference in the diameter of the excised pigmented lesions is significant (Kruskal-Wallis test, PϽ.001). Melanomas in situ and dysplastic nevi undergo biopsy with smaller diameters than common nevi (Wilcoxon signed rank test, PϽ.001).

A B C D

E F

Figure 1. A, Baseline clinical photograph of the left lower leg. The arrow indicates the pigmented lesion that changed. B, Baseline digital epiluminescence microscopic (DELM) image showing a melanocytic nevus with a central area surrounded by a nonuniform network with asymmetrical pigmentation having branched streaks. C, One-year DELM image showing radial streaming, clumping of the prominent irregular pigment network in the central area, pseudopods, and symmetrical enlargement (original magnification of parts B and C is identical at ϫ30). D, Clinical photograph taken at the time of biopsy showing that the lesion has an irregular border. E, Histopathologic appearance of melanoma in situ (hematoxylin-eosin, original magnification ϫ10). F, Radial intraepidermal nests of severely atypical melanocytes are present at the edge of the lesion (hematoxylin-eosin, original magnification ϫ20).

onstrate almost the same ratio of change in nevi. Be- The changes in nevi that prompted biopsy were an cause 81% of the individuals entered into this study had increase in DELM diameter of 1 mm or more in 1 axis a history of melanoma in situ or invasive melanoma, we and changes in the ELM pigmentary patterns, with the chose to monitor many common junctional nevi with appearance of radial streaming, clumping or broaden- DELM to try to assure the patient that early melanoma ing of the irregular pigment network, peripheral black would not be overlooked. dots, and focal enlargement in 1 dimension. The histo-

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B C D

E F

Figure 2. A, Baseline clinical photographs of the thoracic and lumbar back with multiple scars. Arrows denote the changing lesion. B, Baseline digital epiluminescence microscopic (DELM) image showing an atypical nevus. C, Fourteen-month DELM image taken during the first trimester of pregnancy showing focal enlargement in 1 dimension (change in shape), a peripheral black dot, and a prominent irregular pigment network (original magnification of partsBandCis identical at ϫ30). D, Clinical appearance of the 3-mm lesion before biopsy. E, Histopathologic appearance of the dysplastic compound melanocytic nevus with predominantly junctional proliferation of melanocytes arranged in nests at the sides and bases of elongated rete ridges. Prominent histologic features are bridging of the rete ridges and lamellar and concentric fibrosis of the dermis (hematoxylin-eosin, original magnification ϫ20). F, In the area of the peripheral black dot on DELM, there are nests of nevi with moderate atypia at the tips of the rete ridges (hematoxylin-eosin, original magnification ϫ200).

pathologic correlate of radial streaming is a discrete lin- (Figure 1D).33 Although no single criterion is 100% di- ear array of junctional nests of atypical melanocytes at agnostic of melanoma,34-38 radial streaming, clumping or the periphery of the lesion, as observed in the case of mela- broadening of the irregular pigment network, and pe- noma in situ (Figure 1F).32 The clinical correlation of ripheral black dots may be discriminating features for early radial streaming and pseudopods is an irregular border melanoma. Although the diagnostic sensitivity of ELM

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C D

Figure 3. A, Baseline digital epiluminescence microscopic (DELM) image showing an atypical nevus of the toe. B, One-year DELM image showing focal enlargement in 1 dimension (change in shape) (magnification of parts A and B is identical [original magnification ϫ30]). C and D, The superior area of focal growth shows a mildly dysplastic compound melanocytic nevus with prominent bridging of rete ridges and slight cytologic atypia (hematoxylin-eosin, original magnification ϫ20 and ϫ200, respectively).

Table 3. Frequency of Change in Size and Pigmentation by Histologic Diagnosis*

Change in Size, No. Pigmentary Structural Changes, No.

Clumping Within Appearance of Appearance of Symmetrical Focal Enlargement Asymmetrical the Irregular Radial Streaming, Peripheral Black Dots, Histologic Diagnosis Enlargement (Asymmetrical Shape) Pigmentation Pigment Network Branched Streaks Pseudopods Common nevi (n = 20) 19 1 1 0 0 0 Dysplastic nevi (n = 169) 26 135 29 87 0 1 Melanomas in situ (n = 4) 2 2 1 2 1 2

*More than 1 feature may change in a single pigmented lesion. Regression was not noted in any lesions in this study.

ranges from 88% to 95% in various studies,21,39,40 false- Because of the consequences of a false-negative di- negative diagnosis by dermatoscopy is not theoretical; 4 agnosis, the DELM criteria for excisional biopsy in this of 55 melanomas in a recent study5 were missed by DELM. high-risk population were conservatively defined as fo-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 cal change in size of DELM diameter of 1 mm or greater in any axis or DELM pigmentary change, including ra- Table 4. Patient Confidence in the Dermatologist dial streaming, peripheral black dots, pseudopods, and and Comfort With Surveillance Methods and SSE prominent clumping of the irregular pigment network. Confidence, Comfort, Similarly, in this study of a high-risk population, small, Surveillance Method Mean (SD)* Mean (SD)† clinically atypical nevi at least 3 mm in diameter were Dermatologist: visual examination 1.8 (0.5)‡ 2.4 (0.7)‡ imaged to reduce the risk of missing small-diameter le- before DELM (n = 43) sions at the time of clinical examination and failing to Dermatologist: visual examination 4.5 (0.5) 4.2 (0.4) record them with DELM. Given the increased risk of de- after DELM (n = 43) veloping melanoma in patients in this study, we per- Dermatologist: photographs before 2.6 (0.7)‡ 3.5 (0.7)‡ formed a biopsy on all nevi with changes detected by DELM (n = 57) Dermatologist: photographs after 4.6 (0.5) 4.1 (0.4) DELM. Since 31% to 69% of common nevi also change, DELM (n = 57) the excised lesions included common nevi as well as dys- SSE before DELM; visual examination 2.1 (0.7)‡ 1.8 (0.5)‡ plastic nevi and melanomas in situ.24,25,39,41 Melanomas by dermatologist (n = 43) in situ and dysplastic nevi that underwent biopsy in this SSE after DELM; visual examination 2.9 (0.7) 3.2 (0.9) study had a smaller median diameter than common nevi. by dermatologist (n = 43) Because DELM detects changes in small-diameter mela- SSE before DELM, photographs held 2.7 (0.6)‡ 2.5 (0.6)‡ by patient (n = 57) nomas in situ before they become invasive, observation SSE after DELM; photographs held by 3.6 (1.0) 4.1 (0.9) of clinically atypical nevi becomes feasible and reassur- patient (n = 57) ing to those with the certain knowledge that they will develop more melanomas. Detection at this point also re- Abbreviations: DELM, digital epiluminescence microscopy; SSE, skin sults in less scarring than is caused by wide local exci- self-examination. *A value of 5 indicates high confidence; 1, no confidence. sion of invasive melanoma (Figure 2A). †A value of 5 indicates very comfortable with the surveillance method; Surveillance with DELM can reduce the cost of car- 1, very anxious about the method. ing for patients with multiple atypical nevi compared with ‡Significant (PϽ.001, paired samples test). excision of all their nevi and spares patients the poten- tially painful and unsightly scars from multiple biopsies.42 High-risk patients with periodic surveillance tend Table 5. SSE Performance to have significantly thinner, less invasive melanomas and small-diameter lesions compared with those whose tu- Face Face and mors are self-diagnosed.43-47 Changes in small-diameter Variable No SSE, % Only, % Body, % tumors might be overlooked in the absence of archival SSE before DELM; visual 60* 35* 5* images. The surveillance interval commonly accepted by examination by dermatologist (n = 43) dermatologists is annually or every 4 to 6 months. The SSE after DELM; visual examination 25 30 45 intervals are supported by case reports of patients fol- by dermatologist (n = 43) 21,48 lowed by DELM. In this study, 4 cases of melanoma SSE before DELM; photographs 42* 5* 53* in situ were detected during annual DELM. The surveil- held by patient (n = 57) lance interval is also affected by patient comfort and SSE SSE after DELM; photographs held 12 18 70 performance with detection of suspicious lesions. Pa- by patient (n = 57) tient satisfaction with and confidence in care may be at- Abbreviations: DELM, digital epiluminescence microscopy; SSE, skin tributed to the interpersonal skills of the physician and self-examination. the health care team in addition to the technology.49 *Significant (PϽ.001, paired samples test). In this study, melanomas in situ with a median diameter of 4.2 mm were detected. The smaller diameter the atypical nevi at baseline. If a nevus is imaged at the of melanoma in situ is consistent with the 6-mm diam- annual follow-up examination, it may be retained, but eter used in the ABCD rule for visual examination of in- archiving every annual image needlessly increases the vasive melanoma for lesions that have a period of hori- work of DELM. With this caveat, changes in the current zontal growth along the epidermal-dermal junction before DELM program may promote development of an easier invading the dermis. Since 3 of the 4 melanomas in situ interface for monitoring patients. Digital ELM, a tech- in this study demonstrated ELM features of melanoma, nologically sophisticated method of surveillance, is op- it may be possible to replace the time-consuming meth- timally used to follow individuals with a personal or fam- ods used in this study with dermoscopy, whose use would ily history of melanoma, multiple nevi, and some nevi be extended to include lesions of 3 mm or more in di- having the pathological finding of dysplasia.50-52 ameter. Given the societal cost of advanced melanoma and Accepted for publication April 17, 2003. the suffering of individuals and their families, physician We thank Steven Creech, MS, for biostatistical analy- surveillance of those at risk of developing melanoma is sis of the data. important, but the methods used need to be feasible. Clini- Corresponding author and reprints: June K. Robin- cal examination with a handheld dermatoscope by a der- son, MD, Division of Dermatology, Cardinal Bernardin Can- matologist is readily performed. Total-body photo- cer Center, Loyola University Stritch School of Medicine, graphs used by the dermatologist and the patient for 2160 S First Ave, Room 341, Maywood, IL 60153 (e-mail: archival purposes may be supplemented with DELM of [email protected]).

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