STUDY Incidence of New and Changed Nevi and Melanomas Detected Using Baseline Images and Dermoscopy in Patients at High Risk for Melanoma Jeremy P. Banky, MBBS; John W. Kelly, MDBS; Dallas R. English, PhD; Josephine M. Yeatman, MBBS, FACD; John P. Dowling, MBBS, FRCPA Objective: To determine the incidence of new, changed, Results: The incidence of new, changed, and regressed and regressed nevi and melanomas in a cohort of pa- nevi decreased with increasing age (PϽ.001), whereas tients at high risk for melanoma using baseline total body the incidence of melanomas increased (P=.05). The num- photography and dermatoscopy. ber of dysplastic nevi at baseline was positively associ- ated with the incidence of changed nevi (PϽ.001) and Design: Cohort study of patients at high risk for mela- melanomas (P=.03). The use of baseline photography and noma who underwent baseline cutaneous photography dermatoscopy was associated with low biopsy rates and between January 1, 1992, and December 31, 1997, and early detection of melanomas. The development of mela- had at least 1 follow-up visit by December 31, 1998. noma in association with a preexisting nevus was not di- rectly correlated with a change in a preexisting lesion Setting: Private practice rooms of 1 dermatologist in con- monitored by baseline photography. junction with a public hospital-based, multidisciplinary melanoma clinic in Victoria, Australia. Conclusions: Nevi are dynamic, and only a small per- centage of all new and changed melanocytic lesions are Patients: A total of 309 patients who had at least 1 of the following risk factors for melanoma: personal his- melanomas. Patients younger than 50 years had a lower tory, family history, 100 or more nevi, or 4 or more dys- incidence of melanomas and a higher rate of new, changed, plastic nevi. and regressed nevi when compared with patients older than 50 years. A new or changed pigmented lesion is more Main Outcome Measures: Number of new, changed, likely to be a melanoma in patients older than 50 years. and regressed nevi and melanomas detected and ex- cised during the study interval. Arch Dermatol. 2005;141:998-1006 UTANEOUS SURVEILLANCE Not all of these lesions are suggestive of has been well described as melanoma, and along with dermatos- an effective method for copy, many can be managed with reimag- early detection of mela- ing and further follow-up. This study aims noma.1-5 An important aid to identify the proportion of new and Cto this screening process is baseline cuta- neous photography. This has been re- For editorial comment ported to be an efficient method of detect- ing changes that are suggestive of melanoma see page 1032 and as a means to minimize unnecessary changed lesions that are melanomas, as surgery.1,3,5,6 well as the incidence of melanomas and new, changed, and regressed nevi. Author Affiliations: CME course available at Dermatology Unit (Drs Banky, www.archdermatol.com METHODS Kelly, and Yeatman) and Victorian Melanoma Service With photographic cutaneous surveil- (Drs Banky, Kelly, and PATIENTS Dowling), The Alfred, and The lance, a high incidence of melanoma and Cancer Council Victoria early detection of melanoma in high-risk We recruited patients at the private consult- 1,3,5,7 (Dr English), Victoria, patients has been reported. In follow- ing rooms of 1 dermatologist (J.W.K.) in con- Australia. ing up such patients, many new and junction with the Victorian Melanoma Ser- Financial Disclosure: None. changed pigmented lesions are detected. vice, a state-based multidisciplinary consultative (REPRINTED) ARCH DERMATOL/ VOL 141, AUG 2005 WWW.ARCHDERMATOL.COM 998 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 treatment service for cutaneous melanoma (J.W.K., J.P.B., and Biopsy specimens were not obtained of all changed and new J.P.D.). Between January 1, 1992, and December 31, 1997, pa- pigmented lesions. If melanoma could not be confidently ex- tients 16 years or older who presented to the consulting rooms cluded by clinical examination and dermatoscopy, an exci- for full-body cutaneous examination were assessed for eligi- sional biopsy was performed. All new and changed pigmented bility. Baseline skin surface photography was offered if a pa- lesions not excised were recorded. Pigmented lesions re- tient had at least 1 of the following risk factors for melanoma: moved for cosmetic reasons that were not clinically suggestive 4 or more clinically dysplastic nevi,8,9 100 or more melano- of melanoma were not counted. cytic nevi,8,9 a personal history of melanoma,10,11 or a family his- All melanomas diagnosed on follow-up were recorded as new tory of melanoma.12,13 or changed lesions when compared with baseline photo- All 309 (168 female and 141 male) patients who had base- graphs. All melanomas were examined by a single dermatopa- line photographs and had at least 1 follow-up visit by Decem- thologist (J.P.D.). Tumor type was classified according to ber 31, 1998, were included in the study. Patients were di- McGovern et al16 as superficial spreading melanoma, nodular vided according to their age at the time of photography: younger melanoma, or lentigo maligna melanoma, and the levels of in- than 30 years, 30 to 39 years, 40 to 49 years, and 50 years or vasion were recorded as I through V according to Clark et al.17 older. At entry into the study, patients were advised about their Histologic evidence of an associated nevus and the thickness high risk of melanoma, 3-month self-examination was recom- of the melanomas were also recorded. mended, clinical features of early melanoma were discussed, and appropriate sun protection measures were described. STATISTICAL ANALYSIS IMAGING AND EQUIPMENT Incidence rates were calculated for melanomas, new nevi, nevi that changed, and regressed nevi. Duration of follow-up was Patients had a set of 14 baseline cutaneous photographs, each calculated from the date of photography to the date of the last view defined by easily located anatomical reference points follow-up visit. All relevant lesions were included in the cal- (Figure 1). The scalp, dorsum of hands, palms, soles, and culations, regardless of how many each patient had during fol- genitalia were not routinely photographed. A 35-mm single- low-up. We calculated overall rates and rates separately by the Ͻ Ն lens reflex camera (Nikon FM2; Nikon Corporation, Tokyo, baseline age ( 30, 30-39, 40-49, and 50 years), sex, num- Ͻ Ն Japan) equipped with a 105-mm macromodel lens capable of ber of dysplastic nevi at baseline ( 4, 4-10, 11-20, and 21), Ͻ Ն focusing at a magnification of 1:2 or greater was used. The and total number of nevi ( 100 and 100). Negative bino- patient was positioned in front of a gray background, and 2 mial regression was used to estimate rate ratios, confidence in- electronic studio flashes (1200 W-seconds), each diffused tervals, and P values for each of these variables. using large soft boxes, were positioned at 45° to the patient. The melanoma rate among patients was compared with the This softened any coarse shadows. Color slides were devel- rate in all residents of Victoria by calculating the standardized oped from Fujichrome 100 film (Fujifilm, Tokyo, Japan) and incidence ratio with adjustment for calendar year, sex, and age projected using a Kodak Ektagraphic Projector (Kodak, Roch- in 5-year groups. All in situ and invasive melanomas in the popu- ester, NY). lation of Victoria from 1992 to 1998 and in the patients were included in this analysis (data provided by the Victorian Can- cer Registry on July 26, 2002).18 A jackknife confidence inter- DATA COLLECTION val was constructed to allow for the multiple melanomas per patient. All analyses were performed with Stata statistical soft- The baseline was the date of the patient’s initial cutaneous pho- ware, version 7 (Stata Corporation, College Station, Tex). tography. At a patient’s first examination, the number of dys- plastic nevi was recorded in ranges of 0 to 10, 11 to 20, and 21 or more. In addition, the total number of melanocytic nevi was RESULTS estimated and recorded in ranges of 100 or less and more than 100. PATIENT CHARACTERISTICS A nevus was considered dysplastic if it had both clinical14 and dermatoscopic15 features consistent with the diagnosis. Clini- Table 1 gives the number of patients who met each of cally, a dysplastic nevus had a macular component and showed the eligibility criteria. The median age at baseline was 38 at least 3 of the following 5 clinical features: ill-defined bor- years (age range, 16-74 years). The median number of der, irregularly distributed pigmentation, background ery- follow-up visits following photography was 3 (range, thema, maximum diameter greater than 5 mm, and irregular border.14 1-18). The median length of follow-up was 34 months Follow-up of the patients was scheduled at 3-, 6-, or 12- (range, 2-79 months). month intervals. At each visit, total body cutaneous examina- tion was performed by the study dermatologist (J.W.K.), and CHANGED NEVI all melanocytic nevi were compared with baseline photo- graphs. Using these images, the number of new, changed, and A total of 311 changed nevi were detected. Seventy-one completely regressed nevi was recorded at each visit. No dis- nevi had no data for the type of change detected. Of those tinction was made between common nevi and dysplastic nevi nevi with the change documented, the most frequent and between nevi detected at different anatomical sites when changes were in size (67%), color (15%), and both size recording the incidence of new, changed, and regressed nevi.