The seven-point checklist & melanoma incognito
- 1 The seven-point checklist
- 2 Melanoma incognito
- 2.1 1: Do not use dermoscopy only for suspicious lesions
- 2.2 2: Excise lesions with unspecific pigmented pattern
- 2.3 3: Biopsy spitzoid lesions
- 2.4 4: Biopsy lesions revealing extensive regression features
- 2.5 5: Biopsy lesions showing changes on short-term follow-up
- 2.6 6: Excise pink lesions with an atypical vascular pattern
- 2.7 7: Biopsy lesions without clinical-dermoscopic correlation
The sevenThis glossary term has not yet been described.-pointThis glossary term has not yet been described. checklistis a type of informational job aid used to reduce failure by compensating for potential limits of human memory and attention.
In the latter years, a lot of analytical methods based on scored algorithms have been introduced both to simplify the dermoscopic learning and to improve the early melanomaThis glossary term has not yet been described. detection. The seven-point checklist, published in 1998, represents one of the most and latest validated dermoscopic algorithms due to its high sensitivity and specificity, also when used by non-experts. The seven criteriameasure of how well one variable or set of variables predicts an outcome were originally tested on 342 melanocyticThis glossary term has not yet been described. lesions (117 melanomas and 225 atypical neviNevi that clinically look like melanoma but that histopathologically are not melanomas) and were chosen for their frequent association with melanoma. Three of them were defined as major criteria (atypical networkNetwork with increased variability in the color, thickness, and spacing of the lines of the network; asymmetrically distributed; gray color, blue-white veil and atypical vascular pattern), whereas the remaining 4 were considered as minor (irregular streakslines radial (always at periphery) streaks Reed nevus melanoma recurrent nevus, irregular dotsAny distribution of dots other than dots as described for regular dots./globulesThis glossary term has not yet been described., irregular blotches and regressionThis glossary term has not yet been described. structures)(Table 1).
To validate this algorithmIn mathematics and computer science, an algorithm (Listeni/ˈælɡərɪðəm/ AL-gə-ri-dhəm) is a self-contained sequence of actions to be performed. Algorithms can perform calculation, data processing and automated reasoning tasks., a univariate statistical analysis was used to determine differences between melanoma and neviThis glossary term has not yet been described.. A score of 2 points was assigned to the criteria with odds ratios > 5, (major criteria), while a score of 1 point was assigned to the criteria with odds ratios < 5 (minor criteria). A minimum total score of 3 allows identifying melanoma with a sensitivity of 95% and a specificity of 75%. In other words, at least two dermoscopic criteria (one major and one minor) must be present for a suspicious diagnosisis the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines with variations in the use of logic, analytics, and experience to determine "cause and effect". In systems engineering and computer science, it is typically used to determine the causes of symptoms, mitigations, and solutions. According to a revised, simplified seven-point checklist, the presence of at least one of the seven criteria should allow the diagnosis of melanoma with a sensitivity of 85-93% and a specificity between 45 and 48%.
In 2003 the various dermoscopic algorithms (classical pattern analysisThis glossary term has not yet been described., the ABCDThis glossary term has not yet been described. rule, Menzies' method and the seven-point checklist) were re-evaluated and tested by non-experts. In details, 16 physicians not familiar with dermoscopyDermoscopy is a non invasive diagnostic method. examined imagesThis glossary term has not yet been described. of 20 pigmented lesions using the different methods, before and after an Internet-based training course on dermoscopy. The results showed a significant improvement in the dermoscopic diagnosis of melanoma after the Web training for pattern analysis with the ABCD rule and Menzies' method, but not for the seven-point checklist, which allowed higher sensitivity even before the web course. For this reason, the seven-point checklist is considered among the algorithms with the best sensitivity for the non-expert investigators. Afterwards, in the Consensus Net Meeting on DermoscopyDermoscopy is a non invasive diagnostic method., the value of the seven-point checklist was definitively confirmed.
As previously mentioned, the seven-point checklist allows defining a lesion as suspicious when at least one minor and one major criteria are present (score of 3 or more). Although generally multiple malignantThis glossary term has not yet been described. features are at same time present in a given melanoma, sometimes just one of them is prevalent. Particularly, this is true for lesions showing regression in more than 50 % of the lesion surface (Fig.5) or lesions with spitzoid features .
MelanomaThis glossary term has not yet been described. incognitoThis glossary term has not yet been described.
Melanoma incognito is defined as a difficultneeding much effort or skill to accomplish-to-diagnose melanoma, namely a lesion that appears clinically and, sometimes also dermoscopically, benignis any condition that is harmless in the long run or borderline. However, the following 7 managementThis glossary term has not yet been described. rules can helpRefers to giving assistance or support to others for mutual benefit dermatologists to detect melanomas mimicking benign lesions :
1: Do not use dermoscopy only for suspicious lesions
Melanomas may mimic clinically a variety of benign lesions as nevi, seborrheic keratosisThis glossary term has not yet been described., pyogenic granulomaThis glossary term has not yet been described. and dermatofibromaDermatofibromas are hard solitary slow-growing papules (rounded bumps) that may appear in a variety of colours, usually brownish to tan; they are often elevated or pedunculated. A dermatofibroma is associated with the dimple sign; by applying lateral pressure, there is a central depression of the dermatofibroma.. Dermoscopic examination on all skin lesions is the only way to identify lesions that appear clinically benign but are indeed malignant.
2: Excise lesions with unspecific pigmented pattern
Melanoma, especially the hypo/amelanoyic type, could not show dermoscopic features of melanocytic lesions and be confused with benign and inflammatory lesions. To avoid this mistake, if the pattern of a lesion is not suggestive to determine its nature, the biopsy is mandatory.
3: Biopsy spitzoid lesions
Starbust patternThis glossary term has not yet been described., tipically associated with Spitz nevusThis glossary term has not yet been described. of childhood, could be a melanoma clue in adulthood. Thus, all lesions with spitzoid features must be excised in adult patients.
4: Biopsy lesions revealing extensive regression features
RegressionThis glossary term has not yet been described. structures, namely white scar-like areas (corresponding to fibrosis) and blue pepper-like granules (corresponding to melanophages) are alarming bells also in the absence of other melanoma signs, especially in fair skin individuals with multiple nevi. A paper published in 2004 has demonstrated that the risk for a lesion to be a melanoma is directly correlated with the extent of regression seen with dermoscopy. Therefore, lesions showing significant regression structures (in particular more of 50 % of the lesion area) should always be excised independently from its additional dermoscopic features.
5: Biopsy lesions showing changes on short-term follow-up
About 10% of melanomas do not show at the baseline examination clear-cut clinical and dermoscopic features of malignancy. Therefore, flat lesions, moderately atypical, in patients with multiple atypical nevi, must be monitored with digital images and re-evaluated after a short-term follow-up (3 to 6 months). A rapid change at dermoscopic evaluation is sufficient to require excision. However, follow-up is not a good strategy for nodular lesions that must be immediately excised because also a short delay in the treatment of nodular melanomaThis glossary term has not yet been described. might negatively impact on its prognosis.
6: Excise pink lesions with an atypical vascular pattern
Atypical vascular pattern, such as dotted and linear-irregular vesselsThis glossary term has not yet been described., is a malignancy feature, especially for hypo-amelanotic lesions. Therefore, pink lesions showing these features, in absence of other melanoma criteria, should always be biopsied (Fig. 6).
7: Biopsy lesions without clinical-dermoscopic correlation
The lack of correlation between clinical and dermoscopic features is a sufficient reason to perform a biopsy. For example, a lesion that clinically appears like a dermal nevus but dermoscopically doesn't reveal the usual dermal nevus features, must be excised (Fig. 7).
Figure 1: A pigmented lesion showing atypical pigment networkNetwork with increased variability in the color, thickness, and spacing of the lines of the network; asymmetrically distributed; gray color (2 points), brown-black blotches (1 point) and a regression area (1 point). The total score is 4 and indicates a suspicious lesion. Histopathologic diagnosis: melanoma (Breslow thickness: 1 mm)
Figure 4: Dermoscopically, the lesion shows peppering in the center (1 point), atypical network (2 points) and irregular globulesGlobules with variability in color, size, shape or spacing and distributed in an asymmetric fashion at the periphery (1 point). The total score is 4. Histopathologic diagnosis: melanoma in situThis glossary term has not yet been described..
Figure 7: This pigmented lesion, clinically resembling a dermal nevusThis glossary term has not yet been described., shows at dermoscopic examination blue-white veil in center, brown-black globules and whitish irregular linesstreaks. The lack of correlation between the clinical and dermoscopic features imposes the excision. Histopathologic diagnosis: melanoma (Breslow thickness: 0.9 mm)
ReferencesThis glossary term has not yet been described.
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