Dermoscopic evaluation of amelanotic and hypomelanotic melanoma

Objective To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma. Design A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions. Setting Predominantly hospital-based clinics from 5 continents. Main Outcome Measures Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy. Results The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation. Pure amelanotic primary melanoma of the skin is rare, with the largest series suggesting an incidence of less than 2% of melanomas (although this figure is inflated because amelanotic metastases were included in the study).1 Because evidence of melanin is usually found in amelanotic melanoma histopathologically,2 the difficulty in diagnosing these lesions lies with the clinician and not the pathologist, and a precise clinical definition of melanoma lacking significant pigment would be most useful. Furthermore, since dermoscopic evaluation allows the visualization of pigment not seen with the naked eye, a dermoscopic definition of lesions lacking significant pigment would be most useful and is presented in our study. Although dermoscopic evaluation has been shown to improve the accuracy of pigmented melanoma diagnosis compared with naked eye examination,3 less literature is found regarding melanomas lacking significant pigment.4-8 Still, dermoscopic evaluation has been shown to be superior to naked eye examination for the diagnosis of amelanotic or hypomelanotic melanoma.4 To assess the diagnostic significance of dermoscopic features in these lesions, a large series of melanomas as well as nonmelanocytic and benign melanocytic lesions lacking significant pigment was examined.