Cancer Council Australia Wiki Guidelines 2017

Transcription

1 WHAT IS THE ROLE OF SEQUENTIAL DIGITAL DERMOSCOPY IMAGING IN MELANOMA DIAGNOSIS? Cancer Council Australia Wiki Guidelines 2017

2 SHORT-TERM MONITORING 3 months Any change leads to excision Any melanocytic lesion: Historically stable atypical lesions Historically unstable mildly atypical or banal lesions Diagnostic accuracy: 94% sensitivity 84% specificity (non-lentigo maligna)* * Altamura et al. Arch Dermatol. 2008

3 LONG-TERM MONITORING 6-12 months Specific changes lead to excision Diagnostic accuracy: Specificity 95-96% Sensitivity unknown * Any melanocytic lesion: Patients with multiple atypical nevi Follow-up of short-term monitored lesions *Haenssle JID 2006, Robinson J Arch Dermatol 2004, Kittler J Am Acad Dermatol 2000

4 Kittler et al. J Am Acad Dermatol. 2000;43: n Significant change (4% total) defined as: n n n n n enlargement changes in shape regression color appearance (known dermoscopy structures associated with melanoma)

5 SUMMARY OF SYSTEMATIC REVIEW FOR AUSTRALIAN GUIDELINES DEVELOPMENT

6 1. MONITORING IDENTIFIES DERMOSCOPIC FEATURELESS MELANOMA

7 PERCENTAGE OF DERMOSCOPICALLY FEATURELESS MELANOMA FOUND USING MONITORING Study Short-term monitoring Long-term Non-specified or both % (no.) % (no.) % (no.) Menzies (7/7) Kittler (21/34) 39 (22/57) Haenssle (18/34) Robinson (1/4) Altamura (46/81) Salerni (10/12)

8 2. MONITORING DETECTS A HIGH PROPORTION OF MELANOMA IN BOTH SPECIALIST AND PRIMARY CARE

9 PROPORTION OF MELANOMAS DETECTED Study Setting Type Proportion Haenssle JID 2006 Moloney JAMADerm 2014 Salerni JAAD 2012 Tromme BJD 2012 Salerni DermPracC on 2014 Specialist; mod-high risk Specialist; High risk Specialist; mod-high risk Specialist; routine Specialist; routine Prospective 34 % Prospective 39% Retrospect 61% Prospective 55% Retrospect 12%

10 PROPORTION OF MELANOMAS DETECTED Study Setting Type Proportion Menzies BJD 2009 Rademaker JPrimHealt hcare 2010 General Practice; routine Selfreferral; telemedicine Prospective 33% Retrospect 52%

11 3. LONG-TERM MONITORING IN LOW RISK PATIENTS IS LESS EFFICACIOUS

12 Fuller Dermatol Surg 2007 N=297 Patients with atypical N. All atypical n > 2mm (median 19/patient) Monitored: MM ratio 2972:1 Haenssle Arch Derm 2010 N=461 patients with >50 naevi and <4 atypical naevi Median follow-up 12 mo. 150 visits to detect 1 melanoma Schiffner BJD patients with 272 nevi Median follow-up 24 months No melanomas detected

13 4. MONITORING REDUCES THE BENIGN:MELANOMA EXCISION RATIO AND NO. OF BENIGN LESIONS EXCISED.

14 Menzies BJD 2009 Prospective trial General Practitioners Dermoscopy with or without short-term monitor (51%) Baseline benign:melanoma ratio 9.5:1 which decreased to 3.5:1 (p<0.0005) Tromme BJD 2012 Prospective trial Specialists Monitor (short and long) vs Not Benign:M ratio 2.4/1 vs 8.1/1 (p<0.001)

15 COST DIFFERENCE TROMME PLOS ONE 2014 Belgium dermatologists (short and long term monitoring) Benign:Melanoma ratio excisions 8.1 vs 2.5 (Dermoscopy monitoring) 1,600 vs 1,000 (monitoring) per melanoma detected

16 COST DIFFERENCE: WATTS ET AL. J CLIN ONCOL 2017 AUSTRALIAN HIGH RISK COHORT: Dermoscopy monitoring and total body photography vs Standard Care over 10yrs A$6800 per patient SAVED Earlier detection Reduced excisions

17 RECOMMENDATIONS Evidence-based recommendation To assess individual melanocytic lesions of concern, recommend the use of short-term sequential digital dermoscopy imaging (dermoscopy monitoring) to detect melanomas that lack dermoscopic features of melanoma. Grade B Grade B: Body of evidence can be trusted to guide practice in most situations

18 RECOMMENDATIONS Evidence-based recommendation To assess individual or multiple melanocytic lesions in routine surveillance of high risk patients, recommend the use of long-term sequential digital dermoscopy imaging (dermoscopy monitoring) to detect melanomas that lack dermoscopic features of melanoma. Grade B Grade B: Body of evidence can be trusted to guide practice in most situations

19 Practice point The interval for short-term monitoring is 3 months where any change leads to excision. Where lentigo maligna is in the differential diagnosis it is recommended an additional 3 months of monitoring performed, i.e. total of 6 months. Practice point Only flat or slightly raised lesions should undergo dermoscopy monitoring. Nodular lesions should not be monitored.

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