The Skin Cancer Foundation Journal

MAY 2013

The 2012 edition of The Skin Cancer Foundation Journal features medically reviewed, reader-friendly articles such as tanning, the increasing incidence of skin cancer diagnoses among young women, & the prevalence of melanoma among white males over 50.

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Page 63 of 103

HEALTH (i.e., pink or non-pigmented) melanomas.8,9 These lesions are often symmetric, have regular borders, and lack color variegation. Nonetheless, a melanoma diagnosis should be considered when there is any new or growing pink lesion, whether or not it fts into the ABCDEs [Figure 3]. ENTER THE UGLY DUCkLING classic ABCDE criteria are being biopsied and diagnosed as melanomas, which might otherwise have been missed. In an as-yet unpublished study, our team at Memorial Sloan-Kettering Cancer Center analyzed 253 images of melanomas diagnosed by dermoscopy, fnding that a signifcant number of these lesions did not meet the traditional ABCD criteria.7 For example, "A" for "asymmetry" typically refers only to asymmetry of the silhouette or outline of a lesion, based on the observation that noncancerous lesions are typically round or oval. Using this defnition, our evaluation of the 253 in vivo dermoscopic melanoma images surprisingly demonstrated that 37 percent were "symmetric" lesions. In fact, only 27 percent of all the melanomas were actually asymmetric in contour both horizontally and vertically. However, if asymmetry took into account not only contour but also asymmetric coloring, then 94 percent of the 253 melanomas were asymmetric [Figure 2]. Thus, broadening the defnition of asymmetry might be helpful in educating physicians and patients, and might let fewer melanomas slip through the cracks. MORE REASONS TO ENHANCE THE ABCDEs Other limitations of the standard ABCDE criteria have reinforced the need for additional criteria. For example, the "D" in the ABCDEs has incorrectly convinced many people that melanomas always have a diameter greater than 6 mm, and that lesions under 6 mm are safe. However, in our study of the 253 melanomas, 32 percent measured less than 6 mm. One reason smaller melanomas are being diagnosed more frequently is that public awareness of the warning signs has improved, so they are being discovered earlier in their development. Another reason is that the magnifcation provided by dermoscopy and other imaging tools provides earlier, better information about these smaller lesions. One more shortcoming of the ABCDE criteria is that they don't accurately describe many nodular and amelanotic 62 The ABCDE's limitations have led physicians and scientists to propose appropriate new catchphrases offering more helpful visual criteria for certain kinds of melanomas. The technique that has been most quickly and widely embraced is the "Ugly Duckling" method. While the ABCDEs require evaluation of a specifc lesion's features, the "Ugly Duckling" concept relies on recognition of patterns and variations from those patterns in a given individual.10,11 It has been shown that when untrained persons attempt to apply the ABCDE rule to individual lesions, they have trouble reliably distinguishing benign (harmless) from malignant (cancerous) lesions.12 The "Ugly Duckling" sign instead prompts people to identify the pigmented lesion that does not look like (or sometimes feel like) the surrounding ones. Moles on the same person tend to resemble one another, while melanomas often look different. They are outliers — ugly ducklings that stand out from the fock.13 The outlier lesion may be larger and darker than the surrounding moles, smaller and redder than a group of large, dark surrounding moles, or perhaps even the sole mole on an area of the body — but it stands out as different from its surroundings. This method has proven to be sensitive for the detection of melanoma, even in untrained persons14 [Figure 4]. A few other visual recognition techniques have caught on and proven useful as well, including: • The EFG rule: This previously mentioned acronym, standing for "Elevated, Firm on palpation, and Growing progressively for over a month," has remained in wide use, proving valuable in diagnosing nodular melanomas. • The Blue-Black rule: Also especially valuable with nodular melanomas, it is similar to the "Ugly Duckling" sign in its use of pattern recognition. The Blue-Black rule draws attention to any darkly pigmented lesion containing some dark blue and black color that doesn't resemble other surrounding lesions.15 The blue-black technique has proven more sensitive for nodular melanoma than the ABCDEs, but combining the techniques achieves even higher accuracy. • The Beauty and the Beast sign: In this newer technique, the dermoscopic pattern of the lesion is compared against nine established, typical benign patterns, and if it strays from any of these patterns, a biopsy should be considered.16 SK I N C A NCER FOU N DAT ION JOU R NA L

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