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May 17, 2017 / molehunter

NEC Birmingham presentation on mole mapping with dermoscopy

This (link at foot of this post) is a PDF of a presentation I will be giving today at the NEC. It is an edited version of a presentation given at the British Association of Dermatologists’ dermoscopy course for trainees on 26th April. It is intended for delegates but may be of interest to other dermatology doctors. My sincere thanks to Professor Harald Kittler of the University of Vienna for the use of his excellent images.

The main point of this presentation is that people who have had a previous melanoma, have 100 or more moles, who have some atypical moles (atypical moles =naevi over 5mm diameter which are somewhat irregular in shape and colour but have no clear signs of melanoma) are at increased risk of getting a new melanoma, and that monitoring with photography has been shown by good published scientific studies to pick up their new melanomas at an early, therefore curable, stage. The risk is additive, so if you have 100 moles, several over 5mm and looking a bit odd, and have already had a melanoma-you really should be mole mapped and monitored. One of the studies I cite in the presentation showed that melanoma patients in Florence, Italy, who were monitored, when they developed new melanomas they were picked up earlier and were A THIRD OF THE THICKNESS (0.36mm versus 1.22mm) compared with non monitored people. This could literally be the difference between life and death.

In my opinion, based on the evidence I have seen, mole mapping and monitoring should be getting more attention that it currently is. In particular, I think there is a good case for low risk people (i.e. most white people with 40 or fewer moles) to self-monitor using their own tablet computer or similar device. It’s not complicated-just photograph your back, front, sides, arms, legs, head and neck and get a family member of friend to check you over against the photos every 3 months and report any significant change. Not as good as digital mole mapping and regular review with a dermatologist, in fact we don’t have much published evidence it works, but it’s common sense, harmless and affordable. As things are, only people with high risk factors for a melanoma can expect to be regularly monitored by a dermatologist-especially in the UK where we have far too few dermatologists.

Watch this space for further developments in the area of skin screening for melanoma!

 

NB the PDF contains several links to published data which may be useful.

Birmingham NEC registrars monitoring

May 3, 2017 / molehunter

Subtle melanoma

This pigmented lesion on a middle aged woman’s upper arm had been present for several years. There was some doubt as to whether or not it had changed recently. It was flat to palpation and mildly asymmetrical in shape, outline and colour as the image shows.

thin melanoma very subtle (4) - Copy

A full skin check showed it was the biggest mole on her whole body, the ‘ugly duckling‘ Dermoscopy was performed.

thin melanoma very subtle (2)

This is not a very dramatic image, no colour but brown but 2 very distinct patterns. The upper half, taking a line from about 2 o’clock to 8 o’clock, was a mix of reticular and featureless (not photographed very well) but the lower half is made up of globules (=‘clods’ in the modern descriptive terminology). They are of roughly similar size and colour, but the distribution is highly asymmetrical. On balance, the mole was removed for histology.

It proved to be a thin melanoma, 0.5mm Breslow thickness with zero mitoses so almost certainly cured. 

Learning point: as ever, take a holistic view, and err on the side of caution. Some of the melanoma images I post here are so obviously bizarre that a bright child of  6 or 7 could see they needed cutting out, but not always. The goal is to catch them early. As the melanoma develops, it becomes easier to diagnose but harder to cure.

Also, never forget the ugly duckling sign. This catches more melanomas than any other single factor. The mole that looks different, in any way, from all your other moles deserves attention, especially if it is new or changing.

PS note also the many freckles (solar lentigines/lentigos) on the person’s upper back. These are a sure sign of past sun damage, therefore the risk of a melanoma is somewhat higher than in a person of the same age and skin colour without a load of freckles.

 

 

 

March 22, 2017 / molehunter

Urgent skin cancer referral pathway

This is the PDF (click on link below) of a presentation I am giving this afternoon (22nd March 2017) for Southampton GPs about how to make best use of the 2 week wait urgent skin cancer pathway.

Please note, while we sometimes can remove skin cancers on the day, and will try to do so in the case of nodular melanomas, we can’t guarantee to do this, so don’t tell patients to expect it. Many tumours, e.g. SCCs on the scalp or BCCs on the noseCCG 2 week wait, require a skin graft which is 90 minutes in Day Theatre with a highly experienced skin surgeon, common sense dictates we can’t just provide this off the peg in a busy clinic setting.

CCG 2 week wait

 

 

 

March 20, 2017 / molehunter

funny looking black mole

Here’s another mole that you take one look at and think—UGH!!!!!

case 5 (1)

 

Its ugly, but so was Neil Shroff’s case I posted a few days ago, and that was a harmless seborrhoiec keratosis. Need to get the dermoscope into action.

case 5 (2)

Absolute chaos. Even to a complete beginner, you can see multiple colours, multiple structures, even if you can’t name them.

I can see, from the top of the lesion going clockwise, streaks, an eccentric black blotch, irregular network, asymmetric clods, shiny white streaks, and a blue grey veil. That’s 6 out of 7 of Giuseppe Argenziano’s well validated 7 point check list (the only missing feature being atypical vessels, and there are probably some atypical vessels under all that black.)

Melanoma all the way.

 

 

March 18, 2017 / molehunter

PDF of PCDS Chesford Grange presentation

This is intended for the delegates at today’s Primary Care Dermatology Society spring meeting at Chesford Grange.

PDF FINAL EDIT chesford dermoscopy

March 16, 2017 / molehunter

Melanoacanthoma or black keratosis

Thanks to my friend Dr Neil Shrof for this case.

IMG_4454

 

IMG_4450

Very dark ugly duckling. Is it a nodular melanoma? No. Black seb k, also known as melanoacanthoma. Stuck on appearance and keratin pits. Harmless.

 

 

 

 

March 12, 2017 / molehunter

Pattern analysis of multi component melanoma on dermoscopy

The 2017 South Coast Dermoscopy skin lesion recognition and dermoscopy course has just started with a group of about 75 GPs, dermatology trainees, dermatologists, plastic surgeons, nurses and podiatrists assembling at The Holiday Inn Fareham last Friday.

This is the first case I sent out to our on line case discussion group. I like to put up some easy cases to start with. No plain view to hand. In fact I posted this here a few years back, but never mind, its a nice case.

eureka

This is an obvious melanoma, at one glance. Professor Peter Soyer calls this the heuristic method, after ‘Eureka!’ which means ‘I have it!’.  OK, but why is it a melanoma?

Any of the accepted diagnostic methods will get us there. Let’s start with the 2 step algorithm.

step 1: is it melanocytic?  There are brown globules (clods in the new terminology) particularly from 6 to 9 o’clock. Brown globules are a positive feature for melanocytic lesions. Can we see features of any non-melanocytic lesion (i.e. haemangioma, seborrhoeic keratosis, dermatofibroma etc)? No. So it is melanocytic by default and also on positive grounds (brown globules).

step 2; could it be a melanoma? Yes, because of gross asymmetry and multiple patterns and colours. Therefore excision.

The 3 step pathway. In this, we look for asymmetry, blue-white structures, and atypical network. Our lesion here shows the grossest of asymmetry, not so much of shape but of colour and patterns (which are both more important than geometry). We can see blue-white structures (also called blue white veil) and we can also see atypical network, in this case inverse network (the lacy white net-like structure at right and right of centre.) So again positive.

The 7 point check list of Argenziano.  Please click on the link for a discussion of this 7 point check list.  Again, positive. I can see gross asymmetry, irregular dots and globules, blue-white veil, pseudopods (basically a pseudopod is a blob of the end of a streak) an a few other structures.

Chaos and clues. This is chaotic as it has many structures and colours all mixed up. Step 2 of ‘chaos and clues’ is, having said ‘yes, chaos’ we look for clues, initially to ask the question ‘Is it a seborrheoic keratosis?’ Plainly not, the lesion lacks the fissured keratin, comedo like openings, milia like cysts, cerebriform appearance or looped vessels we expect to see in a seb k. When we look for melanoma clues, they are abundant (see above link to 7 point check list).

using SCOPE, our own mnemonic, we see no Symmetry, many COlours, many Patterns and odd things happening at the Edge.

The lesson being that whichever algorithm or scoring technique we use, this is a melanoma (as proved on histology, 3.5mm Breslow thickness). Professor Harald Kittler has said that experts learn all the algorithms and then invent their own. Sometimes one is better, sometimes another, sometimes a mixture.

Pattern analysis is defined as the simultaneous evaluation of all dermoscopic features of a lesion. The link takes you to a useful discussion on dermnetnz.