Imaging Technologies to Assist in Melanoma Detec3on Prac3cal Considera3ons for Pa3ents with Melanoma/Dysplas3c Nevi

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1 Imaging Technologies to Assist in Melanoma Detec3on Prac3cal Considera3ons for Pa3ents with Melanoma/Dysplas3c Nevi Michael A. MD Assistant ABending, Dermatology Service Memorial Sloan KeBering Cancer Center New York, NY Summer AAD Mee3ng 2017, NYC Saturday, July 29th, 9:40 AM

2 PHOTOGRAPHY & VIDEOTAPING ARE STRICTLY PROHIBITED IN ALL EDUCATIONAL SESSIONS CELL PHONES MUST BE PLACED ON VIBRATE OR TURNED OFF ViolaBons of this policy will result in removal from the session and possible revocabon of meebng registrabon. Session directors will be closely monitoring such occurrences. FOTOGRAFIA E FILMANDO SÃO ESTRITAMENTE PROIBIDOS EM TODAS AS SESSÕES EDUCACIONAIS TELEFONES CELULARES DEVEM SER COLOCADOS EM VIBRAR OU DESLIGADOS Violações desta políbca resultará na remoção de sessão e possível revogação do registo da reunião. Diretores de sessão irão acompanhar de perto tais ocorrências.

3 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Michael A. Marchetti, MD F023 Practical Considerations for Patients with Melanoma or Dysplastic Nevi DISCLOSURES IGNYTA: Consultant Honoraria

4 Objec3ves 1) Iden3fy goals of using imaging technologies to aid melanoma diagnosis 2) Describe prac3cal imaging technologies for melanoma detec3on a. Dermoscopy b. Total body photography c. Sequen3al digital dermoscopic imaging

5 Importance of earlier detec3on Although prognosis of melanoma <1mm is excellent, 27% of deaths in US are secondary to these cancers Balch CM, et al. JCO Geller AC, et al. JAAD. 2011

6 Dermoscopy

7 Three meta-analyses show that dermoscopy improves diagnos3c accuracy for melanoma over naked-eye examina3on alone

8 Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

9 Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

10 Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

11 Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

12 Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

13 Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

14 Maumi Y, et al. Dermatology. 2009

15 Total body photography

16 Total body photography catalogues skin surface

17 Prac3cal Tips For efficiency can train nurse or other staff to perform side-by-side comparison and flag all concerning lesions MD can then evaluate flagged lesions Involve pa3ent SSE aided by TBP

18 TBP improves sensi3vity of SSEs in detec3ng new and changing moles With TBP No TBP 0 Sensi3vity Specificity Oliveria et al. Arch Dermatol. 2004

19 Sequen3al digital dermoscopic imaging (SDDI)

20 Sequen3al dermoscopy imaging (SDI) involves repea3ng dermoscopy images* over 3me to detect change Baseline *Must examine side-by-side on monitor 3-months later

21 Short-term (3-4m) - Monitor suspicious melanocybc lesions without diagnosbc features for melanoma No change benign; nevus 3 months ~99.2% unchanged lesions are benign ANY Change biopsy; melanoma in situ 93-96% melanomas will change w/in 3m 16% benign nevi change w/in 3m 3 months

22 What are suspicious melanocybc lesions without diagnosbc features of melanoma???

23 % sure benign <- Observe Biopsy -> % sure melanoma

24 % sure benign <- Observe <- Benign Biopsy -> Malignant -> % sure melanoma

25 % sure benign <- Observe <- Benign Biopsy -> Malignant -> % sure melanoma This is when I consider 3m STMM

26 % sure benign <- Observe <- Benign Biopsy -> Malignant -> % sure melanoma Do not monitor these lesions!!

27 Long-term (>6m) Monitoring greater number of less suspicious nevi in pabents undergoing long-term screening No or non-significant change 95% of lesions Significant change 4-5% of lesions Melanoma-specific structures Focal changes Asymmetric changes

28 Long-term monitoring 1. Melanoma-specific structures 2. Focal changes - color, structure, size 3. Asymmetric change

29 Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

30 Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

31 Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

32 Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

33 Considera3ons Decrease Sensi3vity Missed melanomas No change N.B. Facial and non-facial lesions suspected to be possible lenbgo maligna melanoma should be monitored for greater than 3-months Altamura, Arch Dermatol. 2008

34 Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

35 Right pa3ent Always give the pt op3on of biopsy today vs. short-term monitoring People who will be returning to see you Right lesion If you worry about the lesion when the pa3ent leaves, call pt back lecture test

36 Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

37 I never completely dismiss a lesion as benign. I state that the lesion has no features of concern today but that if change is noted in the future, the pa3ent should return for prompt re-examina3on. Why? (a) early melanomas are difficult to iden3fy (b) sensi3vity is not 100% (c) melanomas can arise in associa3on with nevi (d) collision tumors are not infrequent (e) I have many pa3ents who tell me their dermatologist said their melanoma was nothing to worry about

38 Use of dermoscopy, SDI, TBP together is complementary and effecbve in monitoring those at high-risk for melanoma JAMA Dermatology pabents, median f/u 3.5 years 75 melanomas detected (14 baseline) postbaseline median thickness was in situ 38% TBP; 39% SDI 5 > 1mm thickness (desmo/nodular types) NNB of 4.4 to 1 (melanocybc lesions)

39 Baseline TBSE (clinical and dermoscopy all lesions) SDDI Suspicious/Outlier Biopsy Melanoma Follow-up 1. TBP New, changing, outlier Dermoscopy Suspicious/Outlier Long-term SDDI Concerning change Biopsy Short SDDI Biopsy

40 Thanks