What is the role of skin surface imaging (total body photography) in the early diagnosis of patients at high risk of developing melanoma?

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Introduction

Early detection of melanoma is critical as thinner primary tumours are associated with enhanced survival.[1] Therefore, strategies to improve early detection are important to reduce melanoma-related mortality.

Total body photography (TBP) describes the use of clinical photography to provide a photographic record of patients’ entire skin surface.[2][3] TBP typically includes 12-24 baseline photographs of the skin surface.[4][5][6][7][8] Each view may be defined by easily located anatomical reference points.[5][4] TBP provides a comparative reference point for subsequent examinations and its value derives from the knowledge that melanomas are new or show varying rates of progressive, unremitting change, while the great majority of benign naevi appear stable.[5]

Primary cutaneous melanomas may arise de novo or in association with a pre-existing melanocytic naevus, with the majority arising as de novo lesions.[9][10][11][12][13] TBP facilitates the detection of de novo melanomas which will be identifiable as new lesions arising on normal skin, as well as melanoma presenting as morphologic change in pre-existing melanocytic lesions.

Newness or change in a lesion may be helpful in arousing suspicion of lesions that might not otherwise be suspicious for melanoma (see clinical featues of melanoma), while photographic evidence of the skin surface to demonstrate stability avoids the need for unnecessary biopsies. TBP is undertaken as a baseline record and only needs to be updated when a significant number of changes have occurred, generally every five to ten years. This interval may be shorter in young patients, especially those younger than 30 years, who more frequently develop new and changing benign naevi.[5]

The use of TBP has previously been demonstrated to aid in the early diagnosis of melanoma in high risk patients, particularly in those with a high naevus count or multiple atypical naevi.[14][15][4][3][5][16] Previous research has demonstrated that the use of TBP reduces unnecessary excision of benign lesions[4][3] and increases the sensitivity and specificity of melanoma detection in clinical examination.[3] Not all changed lesions need to be excised. Those that show benign clinical and dermoscopic features can be safely observed. If at any point, there is clinical or dermoscopic evidence for melanoma, excision is recommended.[3] A recent Australian study evaluated the cost-effectiveness of skin surveillance through a specialised clinic for high risk patients, which used both total body photography and digital dermoscopy.[17] This study determined that specialised surveillance through a high risk clinic was both less expensive and more effective than standard care, with melanoma detected at an earlier stage and with few excisions performed.[17]

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Systematic review evidence

More recent studies have confirmed that TBP reduces the biopsy rate of benign naevi and improves diagnostic accuracy of melanoma in high risk patients.[18][6] High risk patients include those with high naevus counts, multiple atypical naevi and high rates of personal and family history of melanoma.

Recent studies have focused on the use of multimodal surveillance methods to aid in early melanoma detection. The “two-step method of digital follow up,” coined by Salerni and colleagues, describes follow up with TBP and sequential digital dermoscopy imaging (SDDI).[19] For a detailed discussion on the role of SDDI in melanoma diagnosis, we refer readers to the chapter in the current guidelines entitled, What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?. Several authors have advocated that a multimodal approach with the combination of TBP and SDDI provides optimal surveillance in high risk patients and may assist with early melanoma diagnosis.[20][21][6][22][23] Melanomas diagnosed by TBP and SDDI have been demonstrated to be thinner compared to those diagnosed by traditional diagnostic methods.[23] As survival is strongly related to Breslow thickness, the combination of TBP and SDDI may confer a survival advantage to patients at high risk of developing melanoma.

TBP has the advantage of monitoring patients’ entire skin surface, rather than a subset of individual lesions. TBP may therefore reveal interval change in pre-existing lesions that were not initially suspicious or atypical on clinical or dermoscopic examination, and as such were not included for SDDI, as well as detecting de novo lesions.[22] A retrospective cohort study determined that a third of melanomas diagnosed during follow up of high risk patients corresponded to lesions that were not under digital dermoscopic surveillance.[22]

An Australian study aimed to assess the impact of TBP and SDDI on melanoma detection in an extreme high risk cohort of patients.[6] In their population, 38% of melanomas were diagnosed either exclusively or aided by TBP, highlighting the value of TBP in melanoma diagnosis.[6]

While SDDI alone is a sensitive tool for detecting subtle dermoscopic change in naevi over time, it is necessarily limited to detecting change in a subset of pre-existing naevi that are under dermoscopic surveillance. A group of investigators evaluated the use of TBP in high risk patients in the context of their prior experience with SDDI in a similar patient population.[24] Monitoring high risk patients with TBP was associated with lower biopsy rates and lower naevus-to-melanoma ratios among biopsied lesions compared to SDDI.[24] TBP was found to have a higher rate of melanoma detection than SSDI and to be a more time-efficient approach.[24]

It is clear that TBP and SDDI provide different evidence for the detection of change in melanoma surveillance and therefore should be applied for different but overlapping indications. TBP provides global imaging evidence and will permit identification of most new or changed lesions wherever these might occur on the skin surface. TBP is particularly suited to patients at elevated risk with high naevus counts and multiple dysplastic naevi. SDDI fulfils a different need for monitoring of one to many individual flat lesions of concern that lack diagnostic clinical or dermoscopic features of melanoma (see: What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?).

One study examined the efficacy of face to face examinations supported by TBP and SDDI compared with teledermatology for both applications.[25] This study was conducted in a high risk population using expert dermatologists. Teledermatology proved equally effective in this study.[25]

There remain no randomised controlled studies that have specifically evaluated the role of TBP in the early diagnosis of melanoma. Indeed, many experts feel that it would not be ethical to randomise high risk individuals to not having TBP.

All of the abovementioned studies were conducted in extreme or high risk cohorts of patients. These techniques are untested in lower risk populations and may not have the same value.

It is well-established that skin self-examination is important in early melanoma detection. The availability of TBP for the patients to use in self-examination may increase their capacity to identify significant change and be reassured about stable lesions. A recent study by Secker et al 2016[26] has demonstrated that less than a third of high risk patients found TBP useful for skin self-examination and none of the five melanomas noticed by patients in the study of Moloney et al. were found using TBP.[6] Those patients in which TBP was found useful was associated with having received instructions on how to perform skin self-examination and confidence at detecting changing moles.[26] This study highlights the importance of promoting a more active role in skin surveillance by patients. Provision of education to patients on the technique of skin self-examination should be a priority for general practitioners and specialists involved in the care of melanoma patients.

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Evidence summary and recommendations

Evidence summary Level References
Five level III-2 studies have demonstrated that a multimodal approach with the combination of total body photography and sequential digital dermoscopy imaging provides effective surveillance in high risk patients and may assist with early melanoma diagnosis. III-2 [20], [21], [6], [19], [23]
Two level IV studies have demonstrated that total body photography may reduce the number of naevus biopsies and improve diagnostic accuracy in high risk melanoma patients. IV [18], [24]
Evidence-based recommendationQuestion mark transparent.png Grade
Consider the use of total body photography in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi.
C


Practice pointQuestion mark transparent.png

TBP allows monitoring of most of the skin surface, including most existing skin lesions. TBP should be the primary imaging intervention for early melanoma detection in patients at elevated risk who have high naevus counts or multiple dysplastic naevi.

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Issues requiring more clinical research study

High-quality prospective studies are required to further investigate the role of TBP in early melanoma diagnosis and its impact on melanoma-related outcomes. In spite of the difficulties of a randomised trial of TBP in high risk patients with high naevus counts, a randomised trial in a large cohort of lower risk individuals would be justifiable. Research is needed to elucidate the optimal risk thresholds for the introduction of both TBP and SDDI to surveillance programs.

Further research should also be directed at assessing the performance of new methods of skin imaging, such as three dimensional imaging, automated detection of change in lesions, teledermatology using TBP and self-assessment of melanocytic lesions using telephone apps.

Total body photography also has the potential to aid skin self-examination by consumers, yet evidence to date would appear to indicate limited impact from uptake by consumers. An important area for future research might be to explore barriers and determinants of skin self-examination and to investigate appropriate methods of educating and empowering consumers with respect to the use of total body photography.

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References

  1. Balch CM, Gershenwald JE, Soong SJ, Thompson JF, Atkins MB, Byrd DR, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol 2009 Dec 20;27(36):6199-206 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19917835.
  2. Halpern AC. Total body skin imaging as an aid to melanoma detection. Semin Cutan Med Surg 2003 Mar;22(1):2-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12773009.
  3. 3.0 3.1 3.2 3.3 3.4 Feit NE, Dusza SW, Marghoob AA. Melanomas detected with the aid of total cutaneous photography. Br J Dermatol 2004 Apr;150(4):706-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15099367.
  4. 4.0 4.1 4.2 4.3 Kelly JW, Yeatman JM, Regalia C, Mason G, Henham AP. A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Med J Aust 1997 Aug 18;167(4):191-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9293264.
  5. 5.0 5.1 5.2 5.3 5.4 Banky JP, Kelly JW, English DR, Yeatman JM, Dowling JP. Incidence of new and changed nevi and melanomas detected using baseline images and dermoscopy in patients at high risk for melanoma. Arch Dermatol 2005 Aug;141(8):998-1006 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16103329.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Moloney FJ, Guitera P, Coates E, Haass NK, Ho K, Khoury R, et al. Detection of primary melanoma in individuals at extreme high risk: a prospective 5-year follow-up study. JAMA Dermatol 2014 Aug;150(8):819-27 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24964862.
  7. Slue W, Kopf AW, Rivers JK. Total-body photographs of dysplastic nevi. Arch Dermatol 1988 Aug;124(8):1239-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3401028.
  8. Halpern AC, Marghoob AA, Bialoglow TW, Witmer W, Slue W. Standardized positioning of patients (poses) for whole body cutaneous photography. J Am Acad Dermatol 2003 Oct;49(4):593-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14512902.
  9. Lin WM, Luo S, Muzikansky A, Lobo AZ, Tanabe KK, Sober AJ, et al. Outcome of patients with de novo versus nevus-associated melanoma. J Am Acad Dermatol 2015 Jan;72(1):54-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25440436.
  10. Bevona C, Goggins W, Quinn T, Fullerton J, Tsao H. Cutaneous melanomas associated with nevi. Arch Dermatol 2003 Dec;139(12):1620-4; discussion 1624 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14676081.
  11. Weatherhead SC, Haniffa M, Lawrence CM. Melanomas arising from naevi and de novo melanomas--does origin matter? Br J Dermatol 2007 Jan;156(1):72-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17199569.
  12. Haenssle HA, Mograby N, Ngassa A, Buhl T, Emmert S, Schön MP, et al. Association of Patient Risk Factors and Frequency of Nevus-Associated Cutaneous Melanomas. JAMA Dermatol 2016 Mar;152(3):291-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26536613.
  13. Shitara D, Nascimento MM, Puig S, Yamada S, Enokihara MM, Michalany N, et al. Nevus-associated melanomas: clinicopathologic features. Am J Clin Pathol 2014 Oct;142(4):485-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25239415.
  14. Shriner DL, Wagner RF Jr. Photographic utilization in dermatology clinics in the United States: a survey of university-based dermatology residency programs. J Am Acad Dermatol 1992 Oct;27(4):565-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1401308.
  15. MacKie RM, McHenry P, Hole D. Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high-risk groups. Lancet 1993 Jun 26;341(8861):1618-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8099990.
  16. Rivers JK, Kopf AW, Vinokur AF, Rigel DS, Friedman RJ, Heilman ER, et al. Clinical characteristics of malignant melanomas developing in persons with dysplastic nevi. Cancer 1990 Mar 1;65(5):1232-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2302671.
  17. 17.0 17.1 Watts CG, Cust AE, Menzies SW, Mann GJ, Morton RL. Cost-Effectiveness of Skin Surveillance Through a Specialized Clinic for Patients at High Risk of Melanoma. J Clin Oncol 2017 Jan;35(1):63-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28034073.
  18. 18.0 18.1 Truong A, Strazzulla L, March J, Boucher KM, Nelson KC, Kim CC, et al. Reduction in nevus biopsies in patients monitored by total body photography. J Am Acad Dermatol 2016 Jul;75(1):135-143.e5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26947450.
  19. 19.0 19.1 Salerni G, Carrera C, Lovatto L, Puig-Butille JA, Badenas C, Plana E, et al. Benefits of total body photography and digital dermatoscopy ("two-step method of digital follow-up") in the early diagnosis of melanoma in patients at high risk for melanoma. J Am Acad Dermatol 2012 Jul;67(1):e17-27 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21683472.
  20. 20.0 20.1 Mintsoulis D, Beecker J. Digital Dermoscopy Photographs Outperform Handheld Dermoscopy in Melanoma Diagnosis. J Cutan Med Surg 2016 Nov;20(6):602-605 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27270098.
  21. 21.0 21.1 Nathansohn N, Orenstein A, Trau H, Liran A, Schachter J. Pigmented lesions clinic for early detection of melanoma: preliminary results. Isr Med Assoc J 2007 Oct;9(10):708-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17987757.
  22. 22.0 22.1 22.2 Salerni G, Carrera C, Lovatto L, Martí-Laborda RM, Isern G, Palou J, et al. Characterization of 1152 lesions excised over 10 years using total-body photography and digital dermatoscopy in the surveillance of patients at high risk for melanoma. J Am Acad Dermatol 2012 Nov;67(5):836-45 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22521205.
  23. 23.0 23.1 23.2 Rademaker M, Oakley A. Digital monitoring by whole body photography and sequential digital dermoscopy detects thinner melanomas. J Prim Health Care 2010 Dec 1;2(4):268-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21125066.
  24. 24.0 24.1 24.2 24.3 Goodson AG, Florell SR, Hyde M, Bowen GM, Grossman D. Comparative analysis of total body and dermatoscopic photographic monitoring of nevi in similar patient populations at risk for cutaneous melanoma. Dermatol Surg 2010 Jul;36(7):1087-98 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20653722.
  25. 25.0 25.1 Arzberger E, Curiel-Lewandrowski C, Blum A, Chubisov D, Oakley A, Rademaker M, et al. Teledermoscopy in High-risk Melanoma Patients: A Comparative Study of Face-to-face and Teledermatology Visits. Acta Derm Venereol 2016 Aug 23;96(6):779-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26776245.
  26. 26.0 26.1 Secker LJ, Bergman W, Kukutsch NA. Total Body Photography as an Aid to Skin Self-examination: A Patient's Perspective. Acta Derm Venereol 2016 Feb;96(2):186-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26315708.

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Appendices


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