Mole or melanoma RCE


Does This Patient Have a Mole or a Melanoma?

Whited, John D., MD, Grichnik, James M., MD, PhD Does This Patient Have a Mole or a Melanoma? JAMA March 4 1998, Vol 279, No 9 (696-701)

Bottom Line

•There are two prediction rules for detecting melanomas. ABCDE (asymmetry, border irregularity, color variegation, diameter > 6mm, elevation) and the Revised 7-point checklist (3 Major signs: Change in size, shape, or color; 4 Minor: inflammation, crusting/bleeding, sensory change, diameter >or = 7mm).

• ABCDE: one or more criteria 92-100% sensitive, Color, border and diameter. Positive required all 3~ 98% specific

• Revised 7-point: 1 major or score > 3 (2 pts for each major feature, 1 for each minor) 79-100% sensitive and 30-37 % specific

•A highly sensitive test is desirable for detecting melanomas which can be deadly. For these rules the fewer criteria required for a positive test the more sensitive but less specific they become.

• Melanoma is unlikely missed if a “positive test” result does not require ALL of the ABCD characteristics to be present.

• Melanoma is unlikely diagnosed as benign using the Revised 7-Point Checklist, however, this method may classify many benign lesions as malignant

SORT Grade of Recommendation: C, small number of low-quality studies reviewed

Comments/Hints/Suggestions

RISK FACTORS FOR MELANOMA: Patients with a personal history or a family history of melanoma are at higher risk, as are patients with a changing nevus, numerous nevi, atypical nevi, or skin that freckles or burns easily with sun exposure; Caucasians and the immunosurpressed are also at risk.

RISK FACTORS NON-MELANOMA SKIN CANCER: previous history, family history, immunosurpression, age 55-75, males, tobacco users, persons with Celtic ancestry, persons with red or blonde hair and those with blue or green eyes are also at risk

Prevalence

Though prevalence was not addressed, incidence, reportedly, is rising. The prevalence of melanoma in the studies reviewed ranged from

Accuracy of Exam

ABCD(E)

Positive LR

Negative LR

Sensitivity

Specificity

Healsmith et al

(Positive was one or more)

---

---

92% (82-96%)

Not given--

McGovern & Litaker

(Only used color, border and diameter. Positive required all 3)

62 (19-170)

0 0-0.5)

100% (54-100%)

98.4% (95-99%)

7-Point

Healsmith et al

(Positive if 1 major feature)

1.6

0

100% (94-100%)

37% (28-46%)

Du Viver et al*

---

---

79% (70-85%)

---

Higgins et al*

---

---

---

30% (21-39%)

*(Score > 3 was positive; 2 pts for each major feature, 1 for each minor)

Global Assessment

Five of the studies this article reviewed showed a correct melanoma diagnosis rate of 41-88% for non-dermatologists compared to 74-100% for dermatologists.

Prediction rules and how symptoms/signs were elicited or defined

Two different approaches to the diagnosis of melanoma were evaluated. The ABCD(E) approach, which is the method most commonly used in the US and the Revised 7-Point Checklist, which is employed in the UK.

The ABCD(E) acronym refers to A: asymmetry, if the lesion, bisected, does not have identical halves; B: border, if the edges of the lesion are not smooth or are jagged and irregular; C: Color variegation, if more than one pigment shade is present within the lesion; D: Diameter, if the length of the lesion is greater than 6mm; (E) Elevation, a proposed characteristic, though not always recognized because many benign lesions are elevated and early melanoma is more often not elevated.

Additionally, any change in a preexisting pigmented lesion or the development of a new pigmented lesion may suggest melanoma. Each of the aforementioned characteristics are worrisome, however, there is no rule quantifying how many of these warrant a biopsy; usually biopsies are preformed based on clinical judgment.

The 7-Point checklist has 3 major and 4 minor criteria: The Major: change in size, shape or color; The Minor: inflammation/crusting/bleeding, sensory change, and diameter of or greater than 7mm. The Revised 7-Point Checklist replaces “change in shape” with irregular shape and “change in color” with irregular color; the revised list also emphasizes the minor criteria. Two points are given for each major, 1 for each minor and 3 or more points warrants a lesion evaluation referral.

Precision

Interobserver agreement (measured by Kappa statistic) were as follows:

Asymmetry0.05-0.26

Border irregularity 0.29-0.53

Color variegation 0.38-0.53

Diameter not reported

Elevation 0.41-0.55

Studies description

The authors conducted a MEDLINE literature search for articles from 1966 to 1996 using the following headings: melanoma, skin neoplasms, physical examination, which were combined with sensitivity, specificity, observation, mass screening,and self-examination.

Inclusion criteria: Studies with a quality of evidence score of C or higher (no studies had an A or B, thus all 12 studies were a grade C). No studies evaluated patients from a primary care population.

Search Date: 1996

Number Found and Reviewed: MEDLINE search yielded 713 articles; 20 articles were reviewed (which were those which assessed accuracy)

Quality/Limitations: “Lack of independence between reference standard and the test, leading to verification bias, occurs in the existing literature”; secondly, not all patients in the studies received skin biopsies which is the gold standard for diagnosis; thirdly, physicians participating in a study involving skin evaluation will likely be more focused in their exam

Gold Standards: The diagnosis of Melanoma is made by histopathological evaluation of excised tissue.

Updated SearchDate: 10/21/05

Article: Benelli C et al. The Dermoscopic Versus the Clinical Diagnosis of Melanoma. European Journal of Dermatology. Sept 1999; 9(6): 470-476.

Description: Prospective study based on dermoscopic and clinical evaluation of 401 lesions for melanoma. Sensitivity of 66.6% with ABCDE criteria improved to 80% with the addition of the dermoscopy method, specificity rose from 79.3% to 89.1%.

Critique: Only Abstract available

Level of Evidence: Unknown

Fit: Study reports dermoscopy used in addition to clinical criteria in the screening of pigmented lesions would improve sensitivity without a sacrifice in specificity.

Article: Gachon J, et al First Prospective Study of the Recognition Process of Melanoma in Dermatological Practice. Archives of Dermatology.Apr 2005;141(4):434-8.

Description: Prospective study of 135 dermotologists’ immediate perception of 4036 resected lesions based on lesion morphology and their intuitive diagnostic opinions

Findings: Did not give sensitivity or specificity data in the abstract. Persons most skilled at melanoma detection survey overall pattern and use comparative processes rather than the ABCD algorhythm;.

Critique: Only Abstract available

Level of Evidence: Unknown

Fit: Study projects the possible use of clinical gestalt in lieu of ABCD algorhythm to increase efficiency, but physicians develop gestalt with experience and thus require an algorhythm or practice guidelines until their experience is sufficient, and even then an algorhythm is still helpful.

Article: Thomas L et al.. Semiological Value of ABCDE Criteria in the Diagnosis of Cutaneous Pigmented Tumors. Dermatology. 19918; 197(): 11-17..

Description: Medical records from a melanoma database were obtained prospectively; 460 files were evaluated using the ABCDE criteria (here the “E” criterion was enlargement, not elevation) as were 680 cases of benign pigmented tumors. All cases were controlled histopathologically. Sensitivity of each criteria: A 57%, B 57%, C 65%, D 90%, E 84%; Specificity of each criteria: A 72%, B 71%, C 59%, D 63%, E 90%. Sensitivity using 2 criteria was 89.3%, with 3 criteria 65.5%. Specificity was 65.3% using 2 criteria and 81% using 3.

Critique: Only Abstract available

Level of Evidence: Unknown

Fit: Results from this study support the findings that using more criteria decreases sensitivity while increasing specificity. Using “enlargement” and the “E” criterion appears more sensitive and specific than “elevation”.

Reviewed by: Madeleine Vanstory, MD; Lee Chambliss, MD Date 10/27/05


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