Dr Ian Katz

Summary of April JAAD articles

Favorable long-term outcomes in patients with histologically dysplastic nevi that approach a specimen border

Thomas L. Hocker, MD,a Ali Alikhan, MD,a Nneka I. Comfere, MD,a,b and Margot S. Peters, MDa,b

Rochester, Minnesota

See related letters on pages 682 and 683

Background: Patients with multiple clinically dysplastic nevi are at increased risk for development of melanoma. However, the risk of melanoma arising in a histologically dysplastic nevus (HDN) is unknown.

Objective: We sought to determine the rate of melanoma development in patients with HDNs that approached a microscopic border but were not re-excised.

Methods: We performed a retrospective study of patients evaluated in our dermatology department from January 1, 1980, to December 31, 1989, who had a HDN that extended to within 0.2 mm of a microscopic punch, shave, or excision border and was not re-excised.

Results: The average follow-up in our cohort of 115 patients was 17.4 years (range: 0.0-29.9): 82 patients (71.3%) were followed up for longer than 10 years, 78 (67.8%) longer than 15 years, and 73 (63.4%) had more than 20 years of follow-up; 66 of 115 nevi were mildly dysplastic, 42 moderately dysplastic, and 7 had severe dysplasia. No patient developed metastatic melanoma or melanoma at the site of removal of a HDN.

Limitations: This was a retrospective study performed at 1 large academic medical center.

Conclusion: During a long-term follow-up period, no patient developed melanoma at the site of an incompletely or narrowly removed HDN, providing evidence that routine re-excision of mildly or moderately dysplastic nevi may not be necessary. ( J Am Acad Dermatol 2013;68:545-51.)



Negative pigment network: An additional dermoscopic feature for the diagnosis of melanoma

Maria A. Pizzichetta, MD,a Renato Talamini, ScD,a Ash A. Marghoob, MD,b H. Peter Soyer, MD,c Giuseppe Argenziano, MD,d Riccardo Bono, MD,e M. Teresa Corradin, MD,f Vincenzo De Giorgi, MD,g Marian A. Gonzalez, MD,h Isabel Kolm, MD,I Andrew W. Kopf, MD,j Joseph Malvehy, MD,k Niccolo Nami, MD,  Margaret Oliviero, MD,I Giovanni Pellacani, MD,m Susana Puig, MD,k Harold Rabinovitz, MD,I Pietro Rubegni, MD,l Stefania Seidenari, MD,m Ignazio Stanganelli, MD,n Andrea Veronesi, MD,a Iris Zalaudek, MD,o Pierfrancesco Zampieri, MD,h and Scott W. Menzies, MB, BS, PhDp Aviano, Reggio Emilia, Rome, Pordenone, Florence, Merano, Siena, Modena, and Meldola, Italy; New  York, New York; Miami, Florida; Barcelona, Spain; Graz, Austria; and Brisbane and Sydney, Australia

Background: The negative pigment network (NPN) is seen as a negative of the pigmented network and it is purported to be a melanoma-specific structure.

Objectives: We sought to assess the frequency, sensitivity, specificity, and odds ratios (ORs) of NPN between melanoma cases and a group of control lesions.

Methods: Digitalized images of skin lesions from 679 patients with histopathological diagnosis of dermatofibroma (115), melanocytic nevus (220), Spitz nevus (139), and melanoma (205) were retrospectively collected and blindly evaluated to assess the presence/absence of NPN.

Results: The frequency of occurrence of NPN was higher in the melanoma group (34.6%) than in Spitz nevus (28.8%),melanocytic nevus (18.2%), and dermatofibroma (11.3%) groups. An OR of 1.8 emerged for the diagnosis of melanoma in the presence of NPN as compared with nonmelanoma diagnosis. Conversely, for melanocytic nevi and dermatofibromas the OR was very low (0.5 and 0.3, respectively). For Spitz nevi the OR of 1.1 was not statistically significant. When comparing melanoma with dermatofibroma, melanocytic nevus, and Spitz nevus, we observed a significantly higher frequency of multicomponent pattern (68.1%), asymmetric pigmentation (92.9%), irregularly distributed NPN (87.3%), and peripheral location of NPN (66.2%) in melanomas.

Limitations: Further studies can provide the precise dermoscopic-histopathologic correlation of NPN in melanoma and other lesions.

Conclusions: The overall morphologic pattern of NPN, such as the irregular distribution and the peripheral location of NPN, along with the multicomponent pattern and the asymmetric  pigmentation could be used as additional features in distinguishing melanoma from Spitz nevus and other benign lesions.

( J Am Acad Dermatol 2013;68:552-9.)



Nodular melanoma: A distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia

Victoria Mar, MBBS, FACD,a,b,c Hugh Roberts, MBBS, FACD,a Rory Wolfe, BSc, PhD,a,b Dallas R. English, BSc, PhD,d,e and John W. Kelly, MBBS, FACD, MDa Melbourne, Australia

Background: There is a growing body of evidence that nodular melanoma (NM), because of its association with increased growth rate and thickness at diagnosis, accounts for a substantial proportion of melanoma deaths.

Objective: We sought to assess the contribution of NM to melanoma deaths in comparison with other tumor subtypes.

Methods: Four cohorts were established comprising 5775 cases of invasive primary cutaneous melanoma reported to the Victorian Cancer Registry during 1989, 1994, 1999, and 2004. Original pathology reports were reviewed. Age-standardized melanoma incidence rates were compared from 1989 to 2004 with annual percentage change using Poisson regression.

Results: The incidence of thick tumors ([4 mm) increased by 3.8% (95% confidence interval 1.4 to 6.2) and 2.5% (95% confidence interval 0.5 to 5.5) per year for male and female patients, respectively. The median thickness of NM at diagnosis was 2.6 mm compared with 0.6 mm for superficial spreading melanoma. A third of patients who died from melanoma during the follow-up period had thick tumors ([4 mm), most of which were nodular subtype (61%). NM accounted for 14% of invasive melanomas, but was responsible for 43% of melanoma deaths in a total of 57,461 person-years of follow-up. By comparison, superficial spreading melanoma contributed 56% of invasive melanoma but only 30% of deaths.

Limitations: Pathology review was limited to reports only. Mortality information relied mostly on death certificate information.

Conclusion: The incidence of thick melanomas continues to increase. Nodular melanoma is clinically distinct and the predominant contributor to melanoma-related deaths, representing a public health challenge in reducing skin cancer mortality. ( J Am Acad Dermatol 2013;68:568-75.)

Key words: histologic type; melanoma; melanoma deaths; melanoma incidence; melanoma survival; nodular melanoma; tumor subtype.



Pigmented solar (actinic) keratosis: An underrecognized collision lesion

Hye Jin Chung, MD,a Kelly L. McGuigan, MD,b Katie L. Osley, MD,a Kate Zendell, MD,a and Jason B. Lee, MDa Philadelphia, Pennsylvania, and Annapolis, Maryland

Background: The lack of well-established diagnostic criteria for pigmented solar (actinic) keratosis (PSK) along with its poorly understood etiopathogenesis has contributed to underrecognition.

Objective: The clinical, dermatoscopic, and histopathologic features of PSK and the cause of the pigmentation are elucidated.

Methods: In all, 167 histologic specimens, 22 clinical images, and 17 dermatoscopic images of PSK were reviewed. In 38 cases, Melan-A stained sections were available for analysis.

Results: The majority of the lesions were located on the head and neck (84%). A separate pigmented lesion was adjacent to or admixed within PSK in 138 (83%) of the cases indicating that PSK represents a collision between a nonpigmented solar keratosis and a pigmented lesion. Solar lentigo (72%) was the most commonly associated pigmented lesion followed by seborrheic keratosis and melanoma. PSK was suspected clinically in 17% of the cases. There were no significant differences in the quality and quantity of the melanocytes between pigmented and nonpigmented solar keratosis.

Limitations: This was a single-center retrospective study. The sample sizes were small for the clinical and dermatoscopic images and Melan-A stains.

Conclusion: In the majority of the cases, a collision between a nonpigmented solar keratosis and a separate coexistent pigmented lesion, primarily a solar lentigo, accounts for the pigmentation in PSK rather than from any fundamental changes in the quantity or quality of the melanocytes. The collision phenomenon accounts for the spectrum of the clinical and dermatoscopic features observed in PSK and its underrecognition. ( J Am Acad Dermatol 2013;68:647-53.)

Key words: collision tumor; Melan-A; melanoma; pig


More evidence about aspirin and melanoma risk reduction

Hi all


There has been a huge amount of news about this in the last week, eg:




Notice in the first link they say, not enough evidence to recommend yet but in the second link the dermatologist would recommend if there were no contra-indications





Taking Omega-3 Supplements May Help Prevent Skin Cancer

This came out yesterday

Results of the study, funded by the Association for International Cancer Research, found that taking a regular dose of fish oils boosted skin immunity to sunlight. Specifically, it also reduced sunlight-induced suppression of the immune system, known as immunosuppression, which affects the body’s ability to fight skin cancer and infection. The findings have been published in The American Journal of Clinical Nutrition this month.

Professor Rhodes, who is based in the Photobiology Unit at the University’s School of Medicine and Salford Royal NHS Foundation Trust, said it was the first time the research had been carried out on humans. “There has been research in this area carried out on mice in the past but this is the first time that there has been a clinical trial directly in people,” she said. “It has taken a number of years to get to this stage and the findings are very exciting.

“This study adds to the evidence that omega-3 is a potential nutrient to protect against skin cancer. Although the changes we found when someone took the oil were small, they suggest that a continuous low level of chemoprevention from taking omega-3 could reduce the risk of skin cancer over an individual’s lifetime.”

Patients who volunteered for the trial took a 4g dose of omega-3, which is about one and a half portions of oily fish, daily and were then exposed to the equivalent of either 8, 15 or 30 minutes of summer midday sun in Manchester using a special light machine. Other patients took a placebo, before being exposed to the light machine. Immunosuppression was 50% lower in people who took the supplement and were exposed to 8 and 15 minutes of sun compared with people who did not take the supplement. The study showed little influence on those in the 30 minute group.

The findings are important in the battle against skin cancer because previous research has shown that sunscreens are often applied inadequately and only worn during holiday periods. However, Professor Rhodes stressed that the omega-3 was not a substitute for sunscreen and physical protection, and that omega-3 should be regarded as an additional small measure to help protect skin from sun damage. The fish oil has already been shown to have many beneficial health effects such as helping with cardiovascular disease, meaning taking the supplement could lead to a range of potential health benefits

Hyfrecators and Interference with Implantable Cardiac Devices

I have always wondered if this was an urban myth. It never stopped me using the hyfrecator before!



Investigation of Hyfrecators and Their In Vitro Interference with Implantable Cardiac Devices


BACKGROUND Guidelines exist for minimizing potential electromagnetic interference (EMI) with electrosurgical equipment in patients with cardiac rhythm management (CRM) devices. These guidelines encompass all electrosurgical devices but are not specific for hyfrecators.

OBJECTIVE To investigate the potential interference of CRM devices by hyfrecators.

MATERIALS AND METHODS Using a collagen-based saline gel, three implantable pulse generators (pacemakers) and three implantable cardioverter defibrillators were tested to measure the EMI from two commonly used hyfrecators. The six devices were tested using the hyfrecator under normal use settings and on maximum power.

RESULTS Hyfrecators did not interfere with defibrillators and affected pacemakers only when used in close proximity to the device. For the pacemakers, atrial inhibition was observed at a distance of 3 cm on maximum hyfrecator settings and 1 cm at normal use settings. Ventricular inhibition occurred in very close proximity to the device (<1 cm) or in direct contact.

CONCLUSION Hyfrecators are safe to use in patients with defibrillators and can be used in pacemaker patients within 2 inches of the device perimeter.

Vitamin D Level and Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma Risk

This is a great review of a complex topic. Let me know if you want a copy of the article.



Various associations between serum vitamin D levels and skin cancer have been reported. In this issue, van der Pols et al. observed that baseline 25-hydroxyvitamin D (25OHD) levels above 75 nmol/L were associated with an increased incidence of basal cell carcinoma and melanoma, and a nonstatistically significant decreased incidence of squamous cell carcinoma. Complex factors including sun exposure, skin phototype, and anticarcinogenic and procarcinogenic effects of vitamin D are potential causes of the observed associations.


Journal of Investigative Dermatology (2013) 133, 589–592. doi:10.1038/jid.2012.427

Transection and melanoma survival

I suppose this study supports what we already know




The rate of melanoma transection with various biopsy techniques and the influence of tumor transection on patient survival

Mohsin Mir, MD, C. Stanley Chan, MD, Farhan Khan, MD, MBA, Bhuvaneswari Krishnan, MD,

Ida Orengo, MD, and Theodore Rosen, MD

Houston, Texas


Background: Depth of melanoma invasion is critical because it dictates patient treatment and prognosis.

Recent reports indicate melanoma transection with initial biopsy does not impact patient survival; however,

tumor transection can lead to misdiagnosis and inaccurate staging.


Objective: This study assessed the rate of melanoma transection with various biopsy techniques and the

impact of tumor transection on patient survival.


Methods: We conducted a retrospective review of all melanoma cases at our institution between 2000 and

2008. Of the 490 melanoma cases identified, 479 met inclusion criteria for the study. The transection rates of biopsy techniques were determined. Cases of transected tumors were matched with nontransected cases in a retrospective case-control fashion to evaluate survival.


Results: The rate of melanoma transection was 1.5% for excisional biopsies, 4.1% for punch biopsies, and

9.0% for saucerization biopsies. The means of disease-free survival for the control and transected groups

were 911 days and 832.7 days, respectively (P value .67). Overall survival for the control group was 1073.7

days versus 1012.4 days for the transected group (P value .72).


Limitations: The study used a select population. The sample size of transected biopsies was limited, in

turn limiting the power of the study. Residents performed the majority of biopsies.


Conclusion: Punch and saucerization biopsies were more likely to transect tumors than excisional

biopsies. The transection of melanoma did not affect overall disease-free survival or mortality in the

population studied. ( J Am Acad Dermatol 2013;68:452-8.)

Desmoplastic Melanoma Review

This article is useful




Clinical and Dermoscopic Characteristics of Desmoplastic Melanomas

Objective: To describe and analyze the clinical and dermoscopic characteristics of desmoplastic melanoma (DM) as a function of pathologic subtype and phenotypic traits.

Design: Retrospective case series.

Setting: Eight high-risk dermatology clinics.

Patients: Patients with DM confirmed by histopathologic analysis whose records included a high-quality dermoscopic image.

Main Outcome Measures: Clinical, dermoscopic, and histopathologic features of DM.

Results: A total of 37DMcases were identified. The majority of patients had fair skin, few nevi, and no history

of melanoma. Lentigo maligna was the most frequent subtype of melanoma associated with DM. The most frequent clinical presentation of DM was a palpable and/or indurated lesion located on sun-exposed skin. Fortythree percent of cases were classified as pure DM, and 57% as mixed DM. Pure DM lesions were thicker than mixed DM lesions (4.10 vs 2.83 mm) (P=.22) and were less likely to have an associated epidermal non-DM component (63% vs 100%) (P=.004). Dermoscopically, DMs had at least 1 melanoma-specific structure, the most frequent being atypical vascular structures. Peppering was more frequently seen in pure DM (44% in pure DM vs 24% in mixed DM) (P=.29). In contrast, crystalline structures, polymorphous vessels, and vascular blush were more commonly seen in mixed DM.

Conclusions: Though DM can be difficult to diagnose based on clinical morphologic characteristics alone, dermoscopy has proved to be a useful aid during the evaluation of clinically equivocal lesions or those lesions with a benign appearance. The most common dermoscopic clues observed in DMs included atypical vascular structures, peppering, and occasionally other melanoma specific structures.

JAMA Dermatol.

Published online January 16, 2013.


A Spitzoid lesion

Great to get comments on this case



A Spitzoid lesion

Skin cancer phone apps aren’t very accurate: study

Carrying on with regard to previous discussions about Apps, this has come out this month. I can email the article which is free online to anyone (http://archderm.jamanetwork.com/article.aspx?articleid=1557488#qundefined)




Skin cancer phone apps aren’t very accurate: study

(Reuters Health) – Smartphone applications that use algorithms to analyze skin lesions may not be very good at determining which ones are cancerous, a new study suggests.

The apps are marketed as educational only and so aren’t covered as medical devices under the Food and Drug Administration’s regulations.

But that may not stop some people from relying on the inexpensive toolsinstead of going to see a dermatologist, researchers said – which could mean slower diagnosis of potentially dangerous lesions.

“There’s no substitute, at this point, for a complete skin exam performed by an expert dermatologist for picking up melanoma as well as other skin cancers,” said Dr. Karen Edison, a dermatologist from University of Missouri in Columbia who wasn’t involved in the new study.

“Just sending a picture to someone you don’t know anywhere in the world can be reassuring if it’s very clear that (the lesion) is benign, so that’s a good thing,” she told Reuters Health, “but it’s kind of fraught with other issues that we haven’t grappled with adequately, I don’t think.”

For example, even if an app makes a correct diagnosis of melanoma, that doesn’t necessarily help if the patient doesn’t know where to get a biopsy or doesn’t have insurance to pay for it, Edison said. “We’re all for technology, but we need to keep it in perspective, and make it a tool.”

For the new study, researchers used photos of 188 pre-diagnosed lesions – 60 melanomas and 128 benign lesions – to check the accuracy of four Smartphone apps made to look for melanoma in previously-taken images.

Three of those apps, which cost under $5 to own, use algorithms to determine whether a lesion is likely to be cancerous or not. The fourth sends images to a certified dermatologist for evaluation, at a price of $5 per lesion.

Of the three algorithm-based apps, the most accurate still missed 18 of the 60 melanomas, mistakenly classifying them as lower-risk, Dr. Laura Ferris from the University of Pittsburgh Medical Center in Pennsylvania and her colleagues reported Wednesday in JAMA Dermatology.

App users “need to know that that’s a pretty big risk to take,” Ferris said.

“If you delay removal or evaluation for your melanoma, it gets deeper, and the chance of it spreading and getting deadly really increases with time,” she told Reuters Health.

The dermatologist consultation app did better than the others, misdiagnosing just one out of 53 evaluable images of cancerous lesions.

All but one of the apps classified more than half of the benign, non-cancerous lesions as problematic.

The researchers said they chose not to release the commercial names of the apps evaluated because their purpose was to determine the accuracy of this type of tool, in general.

The website of a similar company that markets an app for skin lesion analysis using real-time photos, SkinVision, cautions customers to, “Never disregard professional medical advice, or delay in seeking it, because of something you have read on SkinVision. Do not rely on information from SkinVision instead of seeking professional medical advice.”

Likewise, the website for the Mole Detective app says, “Always defer to a medical professional if you feel that a mole looks suspicious. Mole Detective’s intent is not to diagnosis but to help you better track the symptoms of melanoma at home.”

Ferris said there are certain dermatology apps that can help patients.

“There are apps that will do things like teach you about melanomas,” she said. “There are ones that will remind you to do your own skin check – that’s great.”

Both researchers said teledermatology – giving people who live in rural areas, for example, the chance to consult with a dermatologist through photos or video – can be useful. Edison, for example, once used it to diagnose a farmer living hours away with melanoma during harvest season.

But they agreed that for now – and probably for the foreseeable future – machines and apps can’t beat in-person exams when it comes to checking for skin cancer.

Pain and skin cancer

I discussed this with a few people last year and came across this article during the holidays.  I do not believe their pain figures for BCC and SCC as they seem far too high. It’s probably because it is a hospital setting and they see more advanced cases.




Pain and Skin Cancer

Pain is a significant predictor of squamous cell carcinoma compared to basal cell carcinoma, according to results of a recent study.

Investigators with Wake Forest University Baptist Medical Center conducted an institutional review board-approved study, analyzing data on 576 nonmelanoma skin cancers (NMSC) from 478 patients with a mean age of 68.8, . Of those patients, 353 had basal cell carcinoma (BCC) and 223 had squamous cell carcinoma (SCC). The patients used a visual analogue scale to rate the pain and itch they experienced.

For both types of NMSC, itch was the most reported symptom, at 43.5% in SCC and 33.4 % in BCC. The pain prevalence was 39.8 % for patients with SCC, compared to 17.7 % of patients with BCC.

With each one-point increment in visual analogue scale for pain, the odds of having SCC rather than BCC increased by 30 %, according to the study. There was nearly a fourfold increase in the likelihood of a patient having SCC versus BCC when the score for pain was greater than two (odds ratio=3.94; 95 % confidence interval, 2.49-6.23).

“With an increasingly aging population, patients often present with numerous BCCs and SCCs, and it is often difficult for the clinician to prioritize lesion biopsy and removal,” the study authors wrote. “Thus, there is a need for better clinical tools to aid the physician in selecting lesions most likely to be SCCs.”

The study was published in the December issue of JAMA Dermatology, formerly Archives of Dermatology.