Melanoma surveillance, detection clinics catch cancer early

Miami - Pigmented lesion clinics or melanoma surveillance and detection clinics have a role in the early detection of melanoma in patients who are at elevated risk of developing a malignant lesion.

“Most of the major dermatology departments, particularly within teaching hospitals, do have programs, or at least individuals, who follow high-risk patients,” says James Grichnik, M.D., Ph.D., F.A.A.D., professor of dermatology and cutaneous surgery and director of the Melanoma Program at Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami. “The goal of the clinics is to find melanomas earlier. We use dermoscopy for a closer clinical look, confocal microscopy to see cellular detail, and total body photos to identify change. If we catch the tumors early, we cure the vast majority of them.”

Melanoma surveillance and detection clinics serve a core function in comprehensive melanoma programs that also include dermatopathology, medical oncology, surgical oncology and radiation oncology, according to Dr. Grichnik.

“With the melanoma program, we can handle patients across the spectrum from infants to elderly and from benign moles to aggressive metastatic disease,” he says. “For primary melanoma detection, most patients do a pretty good job of examining their own skin, and most melanomas grow slowly, such that irregular examinations generally result in detection and removal when the tumor is still thin. Physicians and patients can work together on early detection of melanoma. However, if it is a fast-growing melanoma we are faced with, then all bets are off.”

Detection tools

At present, the use of technologies such as dermoscopy and confocal microscopy are not reimbursed procedures in the U.S., so there is little financial incentive to employ them.

“Clinicians are using them because it is the right thing to do,” he says.

Surveillance clinics use total body photos to reveal the growth of melanomas, and they focus on subgroups of the population, such as those who present with at least one atypical nevus. Lesion stability correlates with benign behavior, Dr. Grichnik notes.

Total body photos, in particular, he adds, will expose the growth of melanomas, but it is important to note that all acquired nevi have an initial growth phase, so lesion growth has to be considered with other factors prior to making the decision to excise.

“If you identify a lesion on a patient that is not clearly benign or malignant on dermoscopic examination, if it appears enlarged compared to total body photos, it will make you more concerned that what you are looking at is an early melanoma,” Dr. Grichnik says. “However, if it has not changed over time, then it is likely benign.”

Melanomas usually do not match the pattern of the other moles on the body, and as they enlarge they become more non-uniform, Dr. Grichnik explains, noting the melanomas can be spotted as “ugly ducklings” amongst other moles on the body.

“These are moles that we have to pay attention to,” he says.

Assessing the ABCDEs

While the ABCDEs of melanoma are effective for discriminating melanomas greater than 6 mm from common nevi, the ABCDEs are not particularly useful for discriminating small early melanomas or melanomas on patients with multiple dysplastic nevi, according to Dr. Grichnik.

“Most clinicians in pigmented lesion clinics are not using ABCDEs,” he says. “We really use different algorithms to catch melanomas earlier.”

Dysplastic or atypical nevi can demonstrate the characteristics of malignant lesions, as per the ABCDEs of melanoma, but in fact be benign, according to Dr. Grichnik.

Indeed, the majority of dysplastic nevi do not evolve to melanoma. He points to the fact that many atypical nevi are removed unnecessarily. One study found that a total of 136 benign lesions were excised for every melanoma in patients with a previous diagnosis of melanoma. At the same time, some melanomas can present an absence of ABCDE features, Dr. Grichnik says.

According to a study published in the Archives of Dermatology in 2005, patients who were under age 50 had a lower incidence of melanomas and a greater rate of new, changed and regressed nevi compared with their counterparts who were 50 and older.

Improving survival

The existence of a melanoma surveillance and detection clinic will catch melanomas when they are thinner, Dr. Grichnik says.

“If you remove melanomas when they are thinner, those patients will do better,” he says. “Patients who have thin tumors will have better overall survival."

The existence of the clinics lessens the potential for a missed diagnosis, and avoids unnecessary biopsies of benign lesions, Dr. Grichnik adds.

“Some people view following these patients as scary because you are dealing with a liability if you miss a melanoma,” he says. “It is something that clinicians need a passion for, in order to do.”

In addition, it’s important that the clinician in a pigmented lesion clinic be able to manage patient anxiety, and that the clinician works closely with a dermatopathologist and understands the diagnostic challenges, Dr. Grichnik notes.

Disclosures: Dr. Grichnik is a major shareholder in DigitalDerm, has received grants and consulted for Spectral Image, and has received grants and consulted for Electro Optical Sciences.