the most valuable clinical sign of all… · viagra and melanoma risk… viagra may increase the...

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Know your enemy…

Cliff Rosendahl MBBS PhD FSCCA

Associate Professor, School of Medicine, The University of Queensland, Australia

It is warm work, And this day may be the last to any of us at a moment. But mark you!I would not be elsewhere for thousands. Horatio Nelson…

The most valuable clinical sign of all…

The break in the pattern…

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CHAOS?

Not excised

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9

CHAOS?

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Melanoma invasive

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Melanoma Nevus Nevus

CHAOS:


CHAOS: Structure


CHAOS: Structure; Colour

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CHAOS: Structure; Colour; Border

Pete

CHAOS?

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CHAOS?


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Sections show dysplastic compound naevus with moderate melanocytic atypia and focal regression. There is no evidence of malignancy. The margins appear well clearappear well clear.

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“deeper levels”

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Sections show dysplastic compound naevus with moderate melanocytic atypia and focal regression. There is no evidence of malignancy. The margins appear well clear.

Multiple deeper levels have been examined in an attempt to better correlate the histology with the dermatoscopy. These show a focus of early level 2 superficial spreading malignant melanoma…

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Five previous melanomasFather died of cerebral metastasis of melanoma aged 55

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Why does the term “dysplastic” naevus persist?


• A stepwise progression model is plausible and appealing

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• For the pathologist it camouflages uncertainty




• For the clinician it sanctifies an unnecessary excision




• For the clinician it sanctifies an unnecessary excision

• For the patient it makes the unnecessary excision acceptable

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To find one melanoma you have to excise up to 10,000 naevi

Tsao H, Bevona C, Goggins W, Quinn T. The transformation rate of moles (melanocytic nevi) into cutaneous melanoma: a population‐based estimate. Arch Dermatol. 2003 Mar;139(3):282–8.

For a 20‐year‐old individual, the lifetime risk of any selected mole transforming into melanoma by age 80 years is approximately 0.03% (1 in 3164) for men and 0.009% (1 in 10800) for women.

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Pigmented SCC insitu

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Melanoma invasive

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Viagra and melanoma risk…

Ever use: Increased risk 1.92 Recent use: Increased risk 1.84

Viagra and melanoma risk…

Viagra may increase the invasiveness of melanoma cells

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Why does acral skin have ridges and furrows?

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“The idea evolved that lesions have lives, just as human beings have; that lesions look very different at different times in their lives just as human beings d d th t t i th li f l i b

Lives and Lesions…

do; and that stages in the lives of lesions can be described and depicted roughly as early, fully developed, and late, just as human beings can be described and depicted as infantile, mature, and old.” A. Bernard Ackerman, M.D. From The Lives of Lesions, page vi (Ardor Scribendi, Ltd, 1983)

Precursor?

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2008 2009

2012

2014

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Clues to Melanoma

RR PPV% NPV% Sensitivity% Specificity%

Pigmented circles 3.7 25 95.93 70.83 76.39

G i l 4 6 26 5 94 2 54 2 83 3Grey circles 4.6 26.5 94.2 54.2 83.3

Incomplete circles 3.0 18.4 93.9 58.3 71.3

Grey colour 8.9 13.3 98.5 95.8 30.6

dot vessels 3.5 33.3 90.6 8.3 98.1

Odds Ratio

Sharply dermarcated border 0.1

White circles N/A (Never)

Clues against Melanoma

Melanoma insitu

2008 2009

Precursor?

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Naevoid lentigo maligna

Melanoma insitu

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Rosendahl C, Drugge E, VolpicelliE, Drugge R. Diagnosis of a clue‐poor minute melanoma assisted by automated multi‐camera‐array total body photography. ‐letter. Australas J Dermatol. In press, accepted for publication 27/2/2015.

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Courtesy David Whiteman

Delusions of Perfection

• I do not miss melanomas (what I don’t see does not exist)…

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What we don’t see, exists



• If I missed a melanoma I would hear about it




He can’t even remember who his doctor was…

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Every invasive melanoma you diagnose on a patient you have examined before has been previously an insitu melanoma and in almost all cases would have been present when you examined the patient previously…




Every invasive melanoma you diagnose on a patient you have examined before has been previously an insitu melanoma and in almost all cases would have been present when you examined the patient previously…

FACT: 1 in 10 of these patients will die from melanoma




• It wasn’t there when he saw me or it wasn’t a melanoma when I saw itwhen I saw it

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FACT: 1 in 10 of these patients will die from melanoma





2008 2009 2014

Actually it was…





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• It is a dermatopathologic over‐call…

Don’t generalise!






Don’t generalise!






• It is probably not biologically significant…

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• It is probably not biologically significant…• (Why? Because you missed it?)

A melanoma is terminated at diagnosis….


• Patient examined by CR. No lesions of concern

• Referred for total body photography and melanographer assessment because high risk (2 previous melanomas)

Aksana Marozava MD (Belarus)MelanographerMelanographer

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Aksana Marozava MD (Belarus)MelanographerMelanographer

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Melanoma insitu

NO Delusions of Perfection

…and this day may be the last to any of us at a moment… Horatio Nelson…

Mea culpa…

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Melanoma insitu

Thank you!

It is warm work, And this day may be the last to any of us at a moment. But mark you!

I would not be elsewhere for thousands…Horatio Nelson

the most valuable clinical sign of all… · viagra and melanoma risk… viagra may increase the...

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