Effectively Using Dermoscopy: A Self- Assessment Quiz
February 2002
T he best chance for survival that people with melanoma have is to find in-situ or early invasive lesions. Dermoscopy is an in vivo non-invasive technique that has been shown to significantly improve the clinical diagnosis of melanocytic, non-melanocytic, benign and malignant skin lesions, and thus melanoma.
Dermoscopy is the standard of care in Europe and 23% of U.S. dermatologists now use the technique (unpublished data, personal communication Al Kopf, M.D.). The following cases are from patients seen in my private practice and in the pigmented lesion clinic at the University of Miami. This quiz represents my understanding of the proper analysis of skin lesions with dermoscopy, which is based on my clinical experience and what’s in the literature. The cases are representative of what might present to you at any time.
True or False Dermoscopy Quiz
Case #1
Diagnosis:
1. Globules are seen, which are primary criteria to diagnose a melanocytic lesion.
T___ F___
2. This is a well-developed cobblestone pattern.
T___ F___
3. There are many variations on the theme of this pattern.
T___ F___
4. Spitz nevi and melanoma can have a similar pattern.
T___ F___
5. The dots and globules in the globular pattern seen in melanoma would be irregular in size and shape.
T___ F___
Case # 2
Diagnosis:
1. Because this lesion is so well demarcated and dark it must be a melanoma.
T___ F___
2. This is the homogenious pattern seen in a blue nevus.
T___ F___
3. This is the parallel pattern seen in acral melanocytic lesions.
T___ F___
4. The parallel-ridge and parallel-furrow patterns are really the same and always indicate benign pathology.
T___ F___
5. You expect to see this pattern in an acral lesion. If it is not present you should include dysplastic nevi or melanoma in your differential diagnosis.
T___ F___
Case # 3
Diagnosis:
1. The differential diagnosis includes melanocytic lesions such as lentiginous nevi, dysplastic nevi and melanoma.
T___ F___
2. Milia-like cysts and follicular opens diagnostic of
seborrheic keratosis are seen.
T___ F___
3. The starburst, cobblestone, globular and homogenous global patterns can be seen in seborrheic keratosis.
T___ F___
4. The brain-like and fingerprint patterns can be seen in seborrheic keratosis.
T___ F___
5. Milia-like cysts and follicular openings are the stereotypical criteria to diagnose seborrheic keratosis, however, there are innumerable variations on the theme of what you can see dermoscopically in seborrheic keratosis.
T___ F___
Case #4
Diagnosis:
1. This lesion lacks the primary criteria to diagnose a melanocytic lesion.
T___ F___
2. This lesion lacks the primary criteria to diagnose a seborrheic keratosis.
T___ F___
3. This lesion lacks the primary criteria to diagnose a dermatofibroma.
T___ F___
4. The vascular pattern in this lesion is one of the primary criteria seen in basal cell carcinoma.
T___ F___
5. The differentiation of amelanotic melanoma from basal cell carcinoma is not always possible clinically or with
dermoscopy.
T___ F___
Case # 5
Diagnosis:
1. Pigment network and branched streaks identify this as a melanocytic lesion.
T___ F___
2. The presence of irregular diffuse hyperpigmentation and radial streaming are diagnostic of melanoma.
T___ F___
3. Even though the concept of melanoma specific criteria exists, they can also be seen in benign melanocytic lesions.
T___ F___
4. With this lesion, it’s not possible to differentiate a dysplastic nevus from melanoma, therefore it should be excised.
T___ F___
5. No single criterion is 100% diagnostic of melanoma.
T___ F___
6. This lesion has a total dermatoscopy score (TDS) of 6.9 when the ABCD rule of dermatoscopy is used. In this case, it could be a false high score.
T___ F___
Case #6
Diagnosis:
1. The presence of globules identify this pigmented lesion as being melanocytic.
T___ F___
2. The differential diagnosis includes: compound, dysplastic, Spitz nevus and melanoma.
T___ F___
3. There is a great deal of symmetry seen and the diagnosis of a Spitz nevus should immediately come to mind.
T___ F___
4. Spitz nevus is usually a pattern recognition diagnosis. The ABCD rule of dermatoscopy should not be applied because you can get a false high total dermatoscopy score (TDS).
T___ F___
Case #7
Diagnosis:
1. The multi-component global pattern with three distinct dermoscopic areas are seen.
T___ F___
2. The multi-component global pattern is considered a melanoma specific criterion.
T___ F___
3. The ABCD rule of dermatoscopy cannot be used to evaluate this lesion because you cannot see the entire lesion.
T___ F___
4. An atypical vascular pattern, blue-whitish veil, irregular pigmentation and irregular dots are identified in this lesion. If the 7- point checklist were used to evaluate this image it would have a score of 6, which is in the melanoma range.
T___ F___
5. Even a novice dermoscopist can see that there is a great deal of asymmetry of color and structure in this lesion and should excise it post haste!
T___ F___
6. There is asymmetry of pattern, more than one color and brown dots, however, this is insufficient criteria to diagnose melanoma using Menzies scoring method.
T___ F___
Case # 8
Diagnosis:
1. The differential diagnosis of this lesion includes all of the following; in situ and invasive amelanotic melanoma, actinic keratosis, compound and dysplastic nevi, a lesion of psoriasis or in-situ squamous cell carcinoma.
T___ F___
2. Melanoma specific criteria from the pattern analysis algorithm are absent therefore, this could not be a serious lesion.
T___ F___
3. This lesion has a low total dermatoscopy score with the ABCD rule of dermatoscopy, so it could not be a melanoma.
T___ F___
4. The only clue that this might be a melanoma is the presence of the atypical vascular pattern.
T___ F___
5. The atypical vascular pattern (AVP) is defined as irregular linear and/or dotted red vessels.
T___ F___
6. Approximately 10% of melanomas are featureless and cannot be diagnosed with dermoscopy.
T___ F___
Case # 9
Diagnosis:
1. Aggregated globules identify this as a melanocytic lesion.
T___ F___
2. This lesion is relatively symmetrical and there are no criteria to suggest that it is a melanoma.
T___ F___
3. Milky-red areas are easily identified, which suggest a vascular lesion.
T___ F___
4.Milky-red areas are one of the vascular patterns that can be seen in melanoma.
T___ F___
5. The presence of milky-red areas in this lesion should prompt the clinician to ask for a second opinion if the pathology report comes back as a dysplastic nevus.
T___ F__
Case #10
Diagnosis:
1. There are site specific criteria on head, neck and acral lesions that one should learn.
T___ F___
2. Site specific criteria do not exist. Lesions on any part of the body all have the same dermoscopic criteria and are analyzed the same way.
T___ F___
3. The pigment network and pseudo-pigment network are simply different terms for the same criterion used in the ABCD rule of dermatoscopy and the 7-point checklist.
T___ F___
4. The rhomboid and annular-granular structures seen in this image are melanoma specific and site specific criteria seen on the head and neck.
T___ F___
5. At times lentigo maligna can be featureless with dermoscopy with no clues to the correct diagnosis.
T___ F___
Case #11
Diagnosis:
1. Even though a pigment network is considered primary criteria to diagnose a melanocytic lesion, it can be seen in pigmented but non melanocytic lesions also.
T___ F___
2. The differential diagnose of this lesion includes a
dermatofibroma and melanoma with regression.
T___ F___
3. Palpation of this lesion will help make the diagnosis in this difficult case.
T___ F___
4. The scar-like central area seen here is considered primary criteria to diagnose a dermatofibroma.
T___ F___
5. If the ABCD rule of dermatoscopy is applied to a dermatofibroma you can get a false high TDS.
T___ F___
Case # 12
Diagnosis:
1. This is a variation on the theme of a globular pattern seen in benign nevi, therefore, you do not have to excise this lesion.
T___ F___
2. Melanoma specific criteria seen include irregular dots, irregular pigmentation and the atypical vascular pattern.
T___ F___
3. Regression is not seen in this lesion.
T___ F___
4. The lesion demonstrates asymmetry of pattern, more than one color but none of the nine positive features in Menzies scoring method are present.
T___ F___
5. Based on that analysis, this is a benign lesion that can be observed.
T___ F___
6. If the pathology report came back as a mildly dysplastic nevus that makes a good dermoscopic CPC correlation and a second pathologic opinion is not indicated.
T___ F___
Case # 13
Diagnosis:
1. Creating digital dermoscopic images isn’t a reliable/practical way to manage patients with dysplastic/atypical nevi.
T___ F___
2. There are no articles in peer reviewed journals describing dermoscopic changes over time.
T___ F___
3. There are no melanoma specific criteria seen in the baseline January 1999 digital dermoscopic image.
T___ F___
4. Studies have shown that any dermoscopic change over time could be seen with an evolving melanoma and those lesions should be excised.
T___ F___
5. The presence of new colors, asymmetric enlargement and pseudopods are significant changes over time and those lesions should be excised to rule out melanoma.
T___ F___
6. Even though in this case the follow-up July 1999 dermoscopic image is larger, darker with the appearance of irregular dots, those are in sufficient changes to warrant an excision.
T___ F___
Suggested Reading
1. Soyer HP, Argenziano G, Chimenti et al. Dermoscopy of pigmented skin lesions. An atlas based on the consensus net meeting on dermoscopy. EDRA Medical Publishing and New Media 2001, Milan Italy.
2. Argenziano G, Soyer HP, De Giorgio, et al. Interactive CD of dermoscopy. EDRA Medical Publishing and New Media 2000, Milan Italy.
3. www.dermoscopy.org Consensus net meeting on dermoscopy (CNMD) 2000. Unifying concepts of dermoscopy.
4. Stolz W, Braun-Falco 0, Bilek P, et al. Color atlas of dermatoscopy 2nd edition 2001, Blackwell Scientific Publications.
5. Menzies S, Crotty KA, Ingvar C, et al. An atlas of surface microscopy of pigmented lesions. McGraw-Hill 1996, Sydney Australia.
6. Johr F, Izakovic J. Should you be using epiluminescence microscopy? Skin and Aging, March 2000; 28-38.
7. Kittler H, Pehamberger H, Wolf K, et al. Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000; 43: 467-476.
8. Menzies S, Gutenev A, Auramidis M, et al. Short- term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001; 13: 1583-1589.
9. Johr F, Menzies S. Lessons on Dermoscopy. Dermatol Surg 2001; 27 (10): 911-912.
1O. Ascierto PA, Palmieri G, Celortan 0, et al. Sensitivity and specificity of epiluminescence microscopy: evaluation on a sample of 2,731 excised cutaneous pigmented lesions. Br J Dermatol 2000; 142: 895-898.
T he best chance for survival that people with melanoma have is to find in-situ or early invasive lesions. Dermoscopy is an in vivo non-invasive technique that has been shown to significantly improve the clinical diagnosis of melanocytic, non-melanocytic, benign and malignant skin lesions, and thus melanoma.
Dermoscopy is the standard of care in Europe and 23% of U.S. dermatologists now use the technique (unpublished data, personal communication Al Kopf, M.D.). The following cases are from patients seen in my private practice and in the pigmented lesion clinic at the University of Miami. This quiz represents my understanding of the proper analysis of skin lesions with dermoscopy, which is based on my clinical experience and what’s in the literature. The cases are representative of what might present to you at any time.
True or False Dermoscopy Quiz
Case #1
Diagnosis:
1. Globules are seen, which are primary criteria to diagnose a melanocytic lesion.
T___ F___
2. This is a well-developed cobblestone pattern.
T___ F___
3. There are many variations on the theme of this pattern.
T___ F___
4. Spitz nevi and melanoma can have a similar pattern.
T___ F___
5. The dots and globules in the globular pattern seen in melanoma would be irregular in size and shape.
T___ F___
Case # 2
Diagnosis:
1. Because this lesion is so well demarcated and dark it must be a melanoma.
T___ F___
2. This is the homogenious pattern seen in a blue nevus.
T___ F___
3. This is the parallel pattern seen in acral melanocytic lesions.
T___ F___
4. The parallel-ridge and parallel-furrow patterns are really the same and always indicate benign pathology.
T___ F___
5. You expect to see this pattern in an acral lesion. If it is not present you should include dysplastic nevi or melanoma in your differential diagnosis.
T___ F___
Case # 3
Diagnosis:
1. The differential diagnosis includes melanocytic lesions such as lentiginous nevi, dysplastic nevi and melanoma.
T___ F___
2. Milia-like cysts and follicular opens diagnostic of
seborrheic keratosis are seen.
T___ F___
3. The starburst, cobblestone, globular and homogenous global patterns can be seen in seborrheic keratosis.
T___ F___
4. The brain-like and fingerprint patterns can be seen in seborrheic keratosis.
T___ F___
5. Milia-like cysts and follicular openings are the stereotypical criteria to diagnose seborrheic keratosis, however, there are innumerable variations on the theme of what you can see dermoscopically in seborrheic keratosis.
T___ F___
Case #4
Diagnosis:
1. This lesion lacks the primary criteria to diagnose a melanocytic lesion.
T___ F___
2. This lesion lacks the primary criteria to diagnose a seborrheic keratosis.
T___ F___
3. This lesion lacks the primary criteria to diagnose a dermatofibroma.
T___ F___
4. The vascular pattern in this lesion is one of the primary criteria seen in basal cell carcinoma.
T___ F___
5. The differentiation of amelanotic melanoma from basal cell carcinoma is not always possible clinically or with
dermoscopy.
T___ F___
Case # 5
Diagnosis:
1. Pigment network and branched streaks identify this as a melanocytic lesion.
T___ F___
2. The presence of irregular diffuse hyperpigmentation and radial streaming are diagnostic of melanoma.
T___ F___
3. Even though the concept of melanoma specific criteria exists, they can also be seen in benign melanocytic lesions.
T___ F___
4. With this lesion, it’s not possible to differentiate a dysplastic nevus from melanoma, therefore it should be excised.
T___ F___
5. No single criterion is 100% diagnostic of melanoma.
T___ F___
6. This lesion has a total dermatoscopy score (TDS) of 6.9 when the ABCD rule of dermatoscopy is used. In this case, it could be a false high score.
T___ F___
Case #6
Diagnosis:
1. The presence of globules identify this pigmented lesion as being melanocytic.
T___ F___
2. The differential diagnosis includes: compound, dysplastic, Spitz nevus and melanoma.
T___ F___
3. There is a great deal of symmetry seen and the diagnosis of a Spitz nevus should immediately come to mind.
T___ F___
4. Spitz nevus is usually a pattern recognition diagnosis. The ABCD rule of dermatoscopy should not be applied because you can get a false high total dermatoscopy score (TDS).
T___ F___
Case #7
Diagnosis:
1. The multi-component global pattern with three distinct dermoscopic areas are seen.
T___ F___
2. The multi-component global pattern is considered a melanoma specific criterion.
T___ F___
3. The ABCD rule of dermatoscopy cannot be used to evaluate this lesion because you cannot see the entire lesion.
T___ F___
4. An atypical vascular pattern, blue-whitish veil, irregular pigmentation and irregular dots are identified in this lesion. If the 7- point checklist were used to evaluate this image it would have a score of 6, which is in the melanoma range.
T___ F___
5. Even a novice dermoscopist can see that there is a great deal of asymmetry of color and structure in this lesion and should excise it post haste!
T___ F___
6. There is asymmetry of pattern, more than one color and brown dots, however, this is insufficient criteria to diagnose melanoma using Menzies scoring method.
T___ F___
Case # 8
Diagnosis:
1. The differential diagnosis of this lesion includes all of the following; in situ and invasive amelanotic melanoma, actinic keratosis, compound and dysplastic nevi, a lesion of psoriasis or in-situ squamous cell carcinoma.
T___ F___
2. Melanoma specific criteria from the pattern analysis algorithm are absent therefore, this could not be a serious lesion.
T___ F___
3. This lesion has a low total dermatoscopy score with the ABCD rule of dermatoscopy, so it could not be a melanoma.
T___ F___
4. The only clue that this might be a melanoma is the presence of the atypical vascular pattern.
T___ F___
5. The atypical vascular pattern (AVP) is defined as irregular linear and/or dotted red vessels.
T___ F___
6. Approximately 10% of melanomas are featureless and cannot be diagnosed with dermoscopy.
T___ F___
Case # 9
Diagnosis:
1. Aggregated globules identify this as a melanocytic lesion.
T___ F___
2. This lesion is relatively symmetrical and there are no criteria to suggest that it is a melanoma.
T___ F___
3. Milky-red areas are easily identified, which suggest a vascular lesion.
T___ F___
4.Milky-red areas are one of the vascular patterns that can be seen in melanoma.
T___ F___
5. The presence of milky-red areas in this lesion should prompt the clinician to ask for a second opinion if the pathology report comes back as a dysplastic nevus.
T___ F__
Case #10
Diagnosis:
1. There are site specific criteria on head, neck and acral lesions that one should learn.
T___ F___
2. Site specific criteria do not exist. Lesions on any part of the body all have the same dermoscopic criteria and are analyzed the same way.
T___ F___
3. The pigment network and pseudo-pigment network are simply different terms for the same criterion used in the ABCD rule of dermatoscopy and the 7-point checklist.
T___ F___
4. The rhomboid and annular-granular structures seen in this image are melanoma specific and site specific criteria seen on the head and neck.
T___ F___
5. At times lentigo maligna can be featureless with dermoscopy with no clues to the correct diagnosis.
T___ F___
Case #11
Diagnosis:
1. Even though a pigment network is considered primary criteria to diagnose a melanocytic lesion, it can be seen in pigmented but non melanocytic lesions also.
T___ F___
2. The differential diagnose of this lesion includes a
dermatofibroma and melanoma with regression.
T___ F___
3. Palpation of this lesion will help make the diagnosis in this difficult case.
T___ F___
4. The scar-like central area seen here is considered primary criteria to diagnose a dermatofibroma.
T___ F___
5. If the ABCD rule of dermatoscopy is applied to a dermatofibroma you can get a false high TDS.
T___ F___
Case # 12
Diagnosis:
1. This is a variation on the theme of a globular pattern seen in benign nevi, therefore, you do not have to excise this lesion.
T___ F___
2. Melanoma specific criteria seen include irregular dots, irregular pigmentation and the atypical vascular pattern.
T___ F___
3. Regression is not seen in this lesion.
T___ F___
4. The lesion demonstrates asymmetry of pattern, more than one color but none of the nine positive features in Menzies scoring method are present.
T___ F___
5. Based on that analysis, this is a benign lesion that can be observed.
T___ F___
6. If the pathology report came back as a mildly dysplastic nevus that makes a good dermoscopic CPC correlation and a second pathologic opinion is not indicated.
T___ F___
Case # 13
Diagnosis:
1. Creating digital dermoscopic images isn’t a reliable/practical way to manage patients with dysplastic/atypical nevi.
T___ F___
2. There are no articles in peer reviewed journals describing dermoscopic changes over time.
T___ F___
3. There are no melanoma specific criteria seen in the baseline January 1999 digital dermoscopic image.
T___ F___
4. Studies have shown that any dermoscopic change over time could be seen with an evolving melanoma and those lesions should be excised.
T___ F___
5. The presence of new colors, asymmetric enlargement and pseudopods are significant changes over time and those lesions should be excised to rule out melanoma.
T___ F___
6. Even though in this case the follow-up July 1999 dermoscopic image is larger, darker with the appearance of irregular dots, those are in sufficient changes to warrant an excision.
T___ F___
Suggested Reading
1. Soyer HP, Argenziano G, Chimenti et al. Dermoscopy of pigmented skin lesions. An atlas based on the consensus net meeting on dermoscopy. EDRA Medical Publishing and New Media 2001, Milan Italy.
2. Argenziano G, Soyer HP, De Giorgio, et al. Interactive CD of dermoscopy. EDRA Medical Publishing and New Media 2000, Milan Italy.
3. www.dermoscopy.org Consensus net meeting on dermoscopy (CNMD) 2000. Unifying concepts of dermoscopy.
4. Stolz W, Braun-Falco 0, Bilek P, et al. Color atlas of dermatoscopy 2nd edition 2001, Blackwell Scientific Publications.
5. Menzies S, Crotty KA, Ingvar C, et al. An atlas of surface microscopy of pigmented lesions. McGraw-Hill 1996, Sydney Australia.
6. Johr F, Izakovic J. Should you be using epiluminescence microscopy? Skin and Aging, March 2000; 28-38.
7. Kittler H, Pehamberger H, Wolf K, et al. Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000; 43: 467-476.
8. Menzies S, Gutenev A, Auramidis M, et al. Short- term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001; 13: 1583-1589.
9. Johr F, Menzies S. Lessons on Dermoscopy. Dermatol Surg 2001; 27 (10): 911-912.
1O. Ascierto PA, Palmieri G, Celortan 0, et al. Sensitivity and specificity of epiluminescence microscopy: evaluation on a sample of 2,731 excised cutaneous pigmented lesions. Br J Dermatol 2000; 142: 895-898.
T he best chance for survival that people with melanoma have is to find in-situ or early invasive lesions. Dermoscopy is an in vivo non-invasive technique that has been shown to significantly improve the clinical diagnosis of melanocytic, non-melanocytic, benign and malignant skin lesions, and thus melanoma.
Dermoscopy is the standard of care in Europe and 23% of U.S. dermatologists now use the technique (unpublished data, personal communication Al Kopf, M.D.). The following cases are from patients seen in my private practice and in the pigmented lesion clinic at the University of Miami. This quiz represents my understanding of the proper analysis of skin lesions with dermoscopy, which is based on my clinical experience and what’s in the literature. The cases are representative of what might present to you at any time.
True or False Dermoscopy Quiz
Case #1
Diagnosis:
1. Globules are seen, which are primary criteria to diagnose a melanocytic lesion.
T___ F___
2. This is a well-developed cobblestone pattern.
T___ F___
3. There are many variations on the theme of this pattern.
T___ F___
4. Spitz nevi and melanoma can have a similar pattern.
T___ F___
5. The dots and globules in the globular pattern seen in melanoma would be irregular in size and shape.
T___ F___
Case # 2
Diagnosis:
1. Because this lesion is so well demarcated and dark it must be a melanoma.
T___ F___
2. This is the homogenious pattern seen in a blue nevus.
T___ F___
3. This is the parallel pattern seen in acral melanocytic lesions.
T___ F___
4. The parallel-ridge and parallel-furrow patterns are really the same and always indicate benign pathology.
T___ F___
5. You expect to see this pattern in an acral lesion. If it is not present you should include dysplastic nevi or melanoma in your differential diagnosis.
T___ F___
Case # 3
Diagnosis:
1. The differential diagnosis includes melanocytic lesions such as lentiginous nevi, dysplastic nevi and melanoma.
T___ F___
2. Milia-like cysts and follicular opens diagnostic of
seborrheic keratosis are seen.
T___ F___
3. The starburst, cobblestone, globular and homogenous global patterns can be seen in seborrheic keratosis.
T___ F___
4. The brain-like and fingerprint patterns can be seen in seborrheic keratosis.
T___ F___
5. Milia-like cysts and follicular openings are the stereotypical criteria to diagnose seborrheic keratosis, however, there are innumerable variations on the theme of what you can see dermoscopically in seborrheic keratosis.
T___ F___
Case #4
Diagnosis:
1. This lesion lacks the primary criteria to diagnose a melanocytic lesion.
T___ F___
2. This lesion lacks the primary criteria to diagnose a seborrheic keratosis.
T___ F___
3. This lesion lacks the primary criteria to diagnose a dermatofibroma.
T___ F___
4. The vascular pattern in this lesion is one of the primary criteria seen in basal cell carcinoma.
T___ F___
5. The differentiation of amelanotic melanoma from basal cell carcinoma is not always possible clinically or with
dermoscopy.
T___ F___
Case # 5
Diagnosis:
1. Pigment network and branched streaks identify this as a melanocytic lesion.
T___ F___
2. The presence of irregular diffuse hyperpigmentation and radial streaming are diagnostic of melanoma.
T___ F___
3. Even though the concept of melanoma specific criteria exists, they can also be seen in benign melanocytic lesions.
T___ F___
4. With this lesion, it’s not possible to differentiate a dysplastic nevus from melanoma, therefore it should be excised.
T___ F___
5. No single criterion is 100% diagnostic of melanoma.
T___ F___
6. This lesion has a total dermatoscopy score (TDS) of 6.9 when the ABCD rule of dermatoscopy is used. In this case, it could be a false high score.
T___ F___
Case #6
Diagnosis:
1. The presence of globules identify this pigmented lesion as being melanocytic.
T___ F___
2. The differential diagnosis includes: compound, dysplastic, Spitz nevus and melanoma.
T___ F___
3. There is a great deal of symmetry seen and the diagnosis of a Spitz nevus should immediately come to mind.
T___ F___
4. Spitz nevus is usually a pattern recognition diagnosis. The ABCD rule of dermatoscopy should not be applied because you can get a false high total dermatoscopy score (TDS).
T___ F___
Case #7
Diagnosis:
1. The multi-component global pattern with three distinct dermoscopic areas are seen.
T___ F___
2. The multi-component global pattern is considered a melanoma specific criterion.
T___ F___
3. The ABCD rule of dermatoscopy cannot be used to evaluate this lesion because you cannot see the entire lesion.
T___ F___
4. An atypical vascular pattern, blue-whitish veil, irregular pigmentation and irregular dots are identified in this lesion. If the 7- point checklist were used to evaluate this image it would have a score of 6, which is in the melanoma range.
T___ F___
5. Even a novice dermoscopist can see that there is a great deal of asymmetry of color and structure in this lesion and should excise it post haste!
T___ F___
6. There is asymmetry of pattern, more than one color and brown dots, however, this is insufficient criteria to diagnose melanoma using Menzies scoring method.
T___ F___
Case # 8
Diagnosis:
1. The differential diagnosis of this lesion includes all of the following; in situ and invasive amelanotic melanoma, actinic keratosis, compound and dysplastic nevi, a lesion of psoriasis or in-situ squamous cell carcinoma.
T___ F___
2. Melanoma specific criteria from the pattern analysis algorithm are absent therefore, this could not be a serious lesion.
T___ F___
3. This lesion has a low total dermatoscopy score with the ABCD rule of dermatoscopy, so it could not be a melanoma.
T___ F___
4. The only clue that this might be a melanoma is the presence of the atypical vascular pattern.
T___ F___
5. The atypical vascular pattern (AVP) is defined as irregular linear and/or dotted red vessels.
T___ F___
6. Approximately 10% of melanomas are featureless and cannot be diagnosed with dermoscopy.
T___ F___
Case # 9
Diagnosis:
1. Aggregated globules identify this as a melanocytic lesion.
T___ F___
2. This lesion is relatively symmetrical and there are no criteria to suggest that it is a melanoma.
T___ F___
3. Milky-red areas are easily identified, which suggest a vascular lesion.
T___ F___
4.Milky-red areas are one of the vascular patterns that can be seen in melanoma.
T___ F___
5. The presence of milky-red areas in this lesion should prompt the clinician to ask for a second opinion if the pathology report comes back as a dysplastic nevus.
T___ F__
Case #10
Diagnosis:
1. There are site specific criteria on head, neck and acral lesions that one should learn.
T___ F___
2. Site specific criteria do not exist. Lesions on any part of the body all have the same dermoscopic criteria and are analyzed the same way.
T___ F___
3. The pigment network and pseudo-pigment network are simply different terms for the same criterion used in the ABCD rule of dermatoscopy and the 7-point checklist.
T___ F___
4. The rhomboid and annular-granular structures seen in this image are melanoma specific and site specific criteria seen on the head and neck.
T___ F___
5. At times lentigo maligna can be featureless with dermoscopy with no clues to the correct diagnosis.
T___ F___
Case #11
Diagnosis:
1. Even though a pigment network is considered primary criteria to diagnose a melanocytic lesion, it can be seen in pigmented but non melanocytic lesions also.
T___ F___
2. The differential diagnose of this lesion includes a
dermatofibroma and melanoma with regression.
T___ F___
3. Palpation of this lesion will help make the diagnosis in this difficult case.
T___ F___
4. The scar-like central area seen here is considered primary criteria to diagnose a dermatofibroma.
T___ F___
5. If the ABCD rule of dermatoscopy is applied to a dermatofibroma you can get a false high TDS.
T___ F___
Case # 12
Diagnosis:
1. This is a variation on the theme of a globular pattern seen in benign nevi, therefore, you do not have to excise this lesion.
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2. Melanoma specific criteria seen include irregular dots, irregular pigmentation and the atypical vascular pattern.
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3. Regression is not seen in this lesion.
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4. The lesion demonstrates asymmetry of pattern, more than one color but none of the nine positive features in Menzies scoring method are present.
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5. Based on that analysis, this is a benign lesion that can be observed.
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6. If the pathology report came back as a mildly dysplastic nevus that makes a good dermoscopic CPC correlation and a second pathologic opinion is not indicated.
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Case # 13
Diagnosis:
1. Creating digital dermoscopic images isn’t a reliable/practical way to manage patients with dysplastic/atypical nevi.
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2. There are no articles in peer reviewed journals describing dermoscopic changes over time.
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3. There are no melanoma specific criteria seen in the baseline January 1999 digital dermoscopic image.
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4. Studies have shown that any dermoscopic change over time could be seen with an evolving melanoma and those lesions should be excised.
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5. The presence of new colors, asymmetric enlargement and pseudopods are significant changes over time and those lesions should be excised to rule out melanoma.
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6. Even though in this case the follow-up July 1999 dermoscopic image is larger, darker with the appearance of irregular dots, those are in sufficient changes to warrant an excision.
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Suggested Reading
1. Soyer HP, Argenziano G, Chimenti et al. Dermoscopy of pigmented skin lesions. An atlas based on the consensus net meeting on dermoscopy. EDRA Medical Publishing and New Media 2001, Milan Italy.
2. Argenziano G, Soyer HP, De Giorgio, et al. Interactive CD of dermoscopy. EDRA Medical Publishing and New Media 2000, Milan Italy.
3. www.dermoscopy.org Consensus net meeting on dermoscopy (CNMD) 2000. Unifying concepts of dermoscopy.
4. Stolz W, Braun-Falco 0, Bilek P, et al. Color atlas of dermatoscopy 2nd edition 2001, Blackwell Scientific Publications.
5. Menzies S, Crotty KA, Ingvar C, et al. An atlas of surface microscopy of pigmented lesions. McGraw-Hill 1996, Sydney Australia.
6. Johr F, Izakovic J. Should you be using epiluminescence microscopy? Skin and Aging, March 2000; 28-38.
7. Kittler H, Pehamberger H, Wolf K, et al. Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000; 43: 467-476.
8. Menzies S, Gutenev A, Auramidis M, et al. Short- term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001; 13: 1583-1589.
9. Johr F, Menzies S. Lessons on Dermoscopy. Dermatol Surg 2001; 27 (10): 911-912.
1O. Ascierto PA, Palmieri G, Celortan 0, et al. Sensitivity and specificity of epiluminescence microscopy: evaluation on a sample of 2,731 excised cutaneous pigmented lesions. Br J Dermatol 2000; 142: 895-898.
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