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 ra- dial 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- Aenhances 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- (REPRINTED) ARCH DERMATOL / VOL 140, JAN 2004 WWW.ARCHDERMATOL.COM 49 ©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 diagno- sis 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.