Detection of melanoma at an early stage is crucial to improving survival rates in melanoma. Accurate diagnosis by current techniques including dermatoscopy remains difficult, and new tools are needed to improve our diagnostic abilities. This article discusses recent advances in diagnostic techniques including confocal scanning laser microscopy, MelaFind, SIAscopy, and noninvasive genomic detection, as well as other future possibilities to aid in diagnosing melanoma. Advantages and barriers to implementation of the various technologies are also discussed.
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The incidence of melanoma is continuing to increase.
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Current methods commonly fail to diagnose melanoma at an early stage.
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Use of dermatoscopy has improved our diagnostic capabilities, but is highly user dependent and commonly misses the diagnosis.
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Recent advances have lead to new diagnostic technologies such as confocal scanning laser microscopy, MelaFind, SIAscopy, noninvasive genomic detection, and many others.
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Systems such as MelaFind are being created to provide an automated diagnosis to improve diagnostic accuracy and decrease the need for biopsy of benign lesions.
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Several barriers to implementation exist, including cost, time needed to become competent in use of new technologies, and lack of insurance reimbursement for use of new modalities.
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Proper implementation of new technologies will, it is hoped, lead to earlier diagnosis of melanoma, decreased mortality and morbidity, fewer biopsies of benign lesions, and decreased cost to the health care system.
Introduction
According to estimates, there will be approximately 70,000 new cases of melanoma and 8800 subsequent deaths in 2011. For 2012 the estimates are 76,250 cases and 9180 deaths. The incidence of melanoma has been steadily increasing and has doubled in recent decades. For lesions with a depth of less than 1 mm, surgical excision is usually curative and 5-year survival rate is 93% to 97%. By contrast, distant metastatic melanoma has an extremely poor prognosis and 5-year survival ranges from 10% to 20%, depending on location of the metastasis. Detection of melanoma at an early stage is critical for improving the survival rate. In addition to decreased survival of late-stage versus early-stage melanoma, the cost of treating a late-stage melanoma is dramatically higher. Recent estimates show the total costs of in situ tumors to be around $4700, whereas a stage IV melanoma has a total cost of approximately $160,000. The cost of treating late-stage melanoma is likely to increase with the implementation of newly approved treatments such as ipilimumab, which costs about $120,000 for a full treatment.
Despite advances in diagnostic aids such as dermatoscopy, detection has remained a significant challenge, and improved methods of accurately diagnosing melanoma are needed. Studies have shown that even for expert dermoscopists, accurately diagnosing melanoma, particularly in small-diameter lesions, is very challenging, with one study showing a biopsy sensitivity of 71% for melanomas of size less than 6 mm. To measure specificity, numerous studies have looked at biopsy ratios (ie, the number of biopsies of benign lesions performed to make the diagnosis of one skin cancer), and numbers vary widely. On the low end, a study from a specialized pigmented lesion clinic showed a biopsy ratio of approximately 5:1 (5 benign lesions per melanoma biopsied). A recent retrospective study involving 8 practitioners at a single institution had a biopsy ratio of 15:1. On the high end, a study involving a single physician over a 14-year period showed a biopsy ratio of more than 500:1 in patients with no history of melanoma. Given these challenges, new diagnostic aids that could help increase both sensitivity and specificity of biopsies would be of great benefit to patients and physicians. Such improvements ( Table 1 ) have the potential to lead to increased diagnosis of early lesions, which would improve survival and lower the overall cost of treating melanoma. In addition, improved diagnostic techniques would lead to fewer biopsies and decreased morbidity to patients.
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