Dermatology: Practical and Conceptual Dermatology Practical & Conceptual Review | Dermatol Pract Concept. 2022;12(03):e2022100 1 Dermoscopy for Cutaneous Melanoma: Under the Eye of Both the Dermatologist and the Legal Doctor Vittorio Bolcato1, Andrea Michelerio2,3 1 Department of Public Health, Experimental and Forensic Medicine, Forensic Medicine Unit, University of Pavia, Pavia, Italy 2 Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, Pavia, Italy 3 Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy Citation: Bolcato V, Michelerio A. Dermoscopy for Cutaneous Melanoma: under the eye of both the dermatologist and the legal doctor. Dermatol Pract Concept. 2022;12(03):e2022100. DOI: https://doi.org/10.5826/dpc.1203a100 Accepted: October 31, 2021; Published: July 2022 Copyright: ©2022 Bolcato et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Andrea Michelerio, MD, Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, 19, and Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy. E-mail: andrea.michelerio01@ universitadipavia.it Worldwide, melanoma is the 20th most common cancer, with 287,723 estimated new cases (1.6% of all cancers) and 60,712 related deaths (0.6% of all cancer deaths) in 2018, and a five-year prevalence of 965,623 cases [1]. Cutaneous melanoma (CM) is by far the most common melanoma sub- type and a potentially fatal disease. Early recognition is of utmost importance to improve the prognosis, since if mel- anoma is diagnosed at noninvasive stage, the patient will be treated by excision of the primary tumor, but if mela- noma becomes invasive, the chance of recovery decreases as invasion thickness increases [2]. Given its dramatic rise in incidence, its predilection for middle-aged patients, and its ability to masquerade as a benign lesion, melanoma is easily misdiagnosed, providing a basis for malpractice claims [3,4]. Dermatoscopy, commonly referred as dermoscopy, is a noninvasive technique allowing microscopic visualization of subsurface skin structure not visible to the naked eye [5]. A trained user, through a hand-held microscope, equipped with a magnification lens and a light source (the dermatoscope), can appreciate the deeper primary morphology of cutane- ous lesions beyond the gross morphologic features, such as size, shape, colors, contours, and topography. This approach improves the diagnostic accuracy for melanoma [6] and the observers confidence in their clinical diagnosis [7]. Unfortunately, even with dermoscopy, some melanomas remain clinically and dermoscopically indistinguishable from other lesions, such as seborrheic keratoses, whose suggestive features might be displayed in up to 18% of melanomas, vascular lesions and pyogenic granulomas, lichen planus-like keratoses, warts, dermatofibromas, ulcers and, finally, from melanocytic nevi, hence difficult to diagnose [8-16]. This is particularly true in patients with atypical mole syndrome, whose nevi share clinically some, or all, the features of CM (the ABCDs: asymmetry, border, irregularity, color variabil- ity, and diameter > 6 mm). A strategy involves the dermoscopic follow‐up of atypi- cal lesions, through sequential digital dermatoscopy imaging, and excision only of those lesions that change over time [17]. 2 Review | Dermatol Pract Concept. 2022;12(03):e2022100 The introduction of digital dermatoscopes or so-called vid- eodermatoscopes (VDS), the sequential digital dermatoscopy imaging (SSDI) and total body photography (TBP) are fur- ther options in the general digital progress within medicine and dermatology. These systems are equipped with high-res- olution color video cameras that reveal monitor images ob- tained using non-polarized or polarized light. They achieve higher magnifications than most common hand-held derma- toscopes and simplify image acquisition, storage, organiza- tion, analysis, and retrieval. These techniques are appreciated and requested by the patients who, however, might do not fully understand the rational of the methods , often believing their nevi are being monitored because at risk of malignant evolution, especially the atypical ones [18]. Indeed, the ac- tual risk of any given nevus of transforming into a melanoma has been estimated to be low, whereas the majority of mela- nomas appear to arise de novo [19], and “atypical” nevi are at no higher risk of developing into a melanoma; rather, the “atypical” nevus is more likely to actually be a melanoma whose dermoscopic features may not differ significantly at baseline from nevi [15]. A discrepancy between patients and physician’ expecta- tions towards VDS and TBP might be even at the base of the doctor-patient relationship, and this is not without danger. The availability of monitoring during follow-up changes the clinician threshold for biopsy suspicious pigmented lesions, resulting in a fall in the sensitivity for melanoma at the first examination, to increase the specificity and the accuracy for melanoma detection at the next evaluation. There are 2 main approaches: short-term follow-up (3 months) is used to make a clinical decision about single, flat or slightly raised suspicious melanocytic lesion, lacking dermoscopic features of melanoma; while medium or long-term monitoring, gen- erally restricted to patients with multiple nevi, mainly aims at comparison of multiple inconspicuous lesions over stan- dard surveillance periods (usually 6 or 12 months) [20]. To work properly, this method of follow-up needs patients’ compliance with follow-up timing. Unfortunately, it has been proven that patients compliance strongly decreases with long-term control visits, with the risk of melanoma un-treatment [21–23], and we cannot exclude this is due to a misunderstanding and miscommunication between patient and physician about how the method works. Moreover, the depth of invasion is the most critical prognostic factor of malignant melanoma, but dermoscopic findings do not allow a reliable evaluation of the tumor thickness, nor a sure distinction between an in situ and an early invasive phase [24-26] and, consequently, diagnosis re- mains only histopathological. The question is of more than academic interest because melanoma is a completely curable disease if diagnosed early, while still in situ. Once it becomes invasive, the diagnosis becomes easier but the best chance for recovery has been lost. It has been widely proven that sequential dermoscopy imaging detects mostly thin incipi- ent melanomas [15,27,28] and patients with these lesions are generally considered to be at low risk for metastasis and melanoma-related death, but it is well known that a portion of this group will eventually experience disease recurrence and risk death from melanoma [29–32]. One can wonder if, comprehensively informed, a patient would rather opt for immediate surgical removal, sacrificing specificity over sen- sitivity. On the other hand, removal of all unusual-appearing nevi, especially in patients with multiple atypical nevi, is usu- ally impractical. The use of TBP might further facilitate the detection of new lesions, as well as visual changes in pre-existing lesions, by providing a comparative reference point of areas of skin for subsequent examinations [33]. During a dermoscopic and clinical visit, we might be tempted to feel that our conversation with a patient suffi- ciently ensures that the patient has freely and knowingly accepted the procedure. However, while dialogue is neces- sary, it is not sufficient for legally documenting informed consent, given that in some countries, Italy and Spain for example, the law stipulates that consent must be given by traceable means, such as in writing [34,35]. The informed consent doctrine has, in fact, three goals: (1) to include patients in the decision-making process; (2) to involve the patient in the choices that affect the psycho-physical aspect; and (3) to ensure the patient is aware of the potential bene- fits and hazards of the treatment [36]. In dermoscopy context, compared with the issue of patient’s follow-up in medicine as a whole, for the several aforementioned issues and regarding especially the third point, proper documentation of the care planning, with in- formation about prognosis, follow-up, and therapeutic ap- proaches, to which the patient consents, is fundamental in the reduction of litigation related to melanoma misdiagnosis, usually seen as diagnostic delay and illicit reduction of sur- vival and/or quality of life. In medicolegal cases, a physician note may provide additional evidence that the physician met the applicable standard of care, while inadequate documen- tation may reduce the likelihood of a successful defense [3]. Of great interest, a recent pronunciation of the II Civil Section of the Genua Tribunal (n. 939/2017) discusses two of the main issue on diagnostic delay for melanoma: at first, the importance of written health records, to identify the followed diagnostic procedure and the proper information; secondly, the need of standard formation of dermatologist about dermoscopy, to avoid, in cases of doubtful lesions, “that there was not even observation with a dermatoscope” [37]. In addition to documentation, photography becomes more widespread in both general dermatological setting, and in dermoscopy, because specific part of the method; Review | Dermatol Pract Concept. 2022;12(03):e2022100 3 photography, in fact, may directly impact patient care by al- lowing the clinician to detect changes in pigmented lesions. A proper patient’s disclosure over picture management must also be added in the medical records [38,39]. Hence, video-dermoscopy and sequential dermoscopy imaging, with their particular characteristics, might need a deep information and appropriate signed written con- sent [36]. At least in Italy, in litigations and trials regarding diagnos- tic delays of melanomas, the study of Lin et al is used to esti- mate the impact on the prognosis: in our opinion the article has to be considered with extreme caution, because only the rate of growth of the lesion, from a histopathological point of view, is investigated, so it is improper to directly convert this data into patients’ prognosis [40]. Consequently, derma- tologists and hospitals might face medicolegal concerns for some months delay, even in case of small and likely in situ melanomas, if not properly diagnosed and followed [41]. Thus, implementing enough instruments and specialists is mandatory to guarantee optimal follow-up and to meet the patients’ needs and expectations. It is important to remem- ber that the specificity for melanoma diagnosis at the second visit, however, increases only for those with experience with the method, hence the need for trained specialists [17,42]. Nowadays, TBP with standard VD is the best standard of care: to identify the best diagnostic tool for CM diagnosis means to define the parameter of the dermatologist dili- gence, namely, to exclude professional liability. Beyond this information, it is critical to understand several key elements, clinical and medicolegal. Melanoma diagnosis remains difficult, with frequent misdiagnosis, so the definition of the dermoscopy “standard of care” and the identification of shared diagnostic guidelines is fundamental. To grant this “standard of care”, it is important to be wary of quick and “magical” solutions, in the era of online diagno- ses, and to refer to renowned centers and specialists on mel- anoma, enhancing clinician professionality. To avoid clinical and judicial delays, patients need to be informed about the aim of dermoscopy for CM diagnosis, and about the rele- vance of follow-up compliance. Moreover, lesion pictures and their storage are part of the diagnostic procedure: the patient must be properly informed, and he/she must properly disclose it. In conclusion, the medicolegal gaze could be useful to the dermoscopist, providing him with a different and better confidence in the method, assuring a greater patient safety and peace of mind of both patient and physician. References 1. Ferlay J, Colombet M, Soerjomataram I, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019;144(8):1941-1953. DOI: 10.1002/ijc.31937. PMID: 30350310. 2. Naik PP. Cutaneous Malignant Melanoma: A Review of Early Diagnosis and Management. World J Oncol. 2021;12(1): 7-19. DOI: 10.14740/wjon1349. PMID: 33738001. PMCID: PMC7935621. 3. Marghoob AA, Changchien L, DeFazio J, et al. The most com- mon challenges in melanoma diagnosis and how to avoid them. Australas J Dermatol. 2009;50(1):1-13; quiz 14-15. DOI: 10.1111/j.1440-0960.2008.00496_1.x. PMID: 19178485. 4. Cirfera V, Toma G, Labrini G. Introduzione allo studio della dermatologia di interesse legale. Prat Medica Aspetti Leg. 2008;2(2):59-60. DOI:10.7175/pmeal.v2i2.385. 5. Sonthalia S, Pasquali P, Agrawal M, et al. Dermoscopy Update: Review of Its Extradiagnostic and Expanding Indications and Future Prospects. Dermatol Pract Concept. 2019;9(4):253-264. DOI: 10.5826/dpc.0904a02. PMID: 31723457. PMCID: PMC6830565. 6. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic ac- curacy of dermoscopy. Lancet Oncol. 2002;3(3):159-165. DOI: 10.1016/s1470-2045(02)00679-4. PMID: 11902502. 7. Wang SQ, Dusza SW, Scope A, Braun RP, Kopf AW, Marghoob AA. Differences in dermoscopic images from nonpolarized der- moscope and polarized dermoscope influence the diagnostic accuracy and confidence level: a pilot study. Dermatol Surg. 2008;34(10):1389-1395. DOI: 10.1111/j.1524-4725.2008. 34293.x. PMID: 18637816.8. 8. Carrera C, Segura S, Aguilera P, et al. Dermoscopic Clues for Diagnosing Melanomas That Resemble Seborrheic Keratosis. JAMA Dermatol. 2017;153(6):544-551. DOI: 10.1001/jamader- matol.2017.0129. PMID: 28355453; PMCID: PMC5540029. 9. Zaballos P, Llambrich A, Cuéllar F, Puig S, Malvehy J. Dermoscopic findings in pyogenic granuloma. Br J Dermatol. 2006;154(6):1108- 1111. DOI: 10.1111/j.1365-2133.2006.07193.x. PMID: 16704641. 10. Braun RP, Gaide O, Oliviero M, et al. The significance of mul- tiple blue-grey dots (granularity) for the dermoscopic diagno- sis of melanoma. Br J Dermatol. 2007;157(5):907-913. DOI: 10.1111/j.1365-2133.2007.08145.x. PMID: 17725673. 11. Deng W, Yu R, Cui Y, Zheng Z. Amelanotic acral melanoma mis- diagnosed as verruca plantaris. An Bras Dermatol. 2019;94(1): 86-88. DOI: 10.1590/abd1806-4841.20197568. PMID: 30726470. PMCID: PMC6360959. 12. Blum A, Bauer J. Atypical dermatofibroma-like pattern of a melanoma on dermoscopy. Melanoma Res. 2003;13(6):633- 634. DOI: 10.1097/00008390-200312000-00015. PMID: 14646629. 13. Cantwell P, Van Dam H. Acral Amelanotic Melanoma Mim- icking a Non-Healing Arterial Ulcer. Case Rep Dermatol. 2019;11(1):77-81. DOI: 10.1159/000499155. PMID: 31097933. PMCID: PMC6489097. 14. Skvara H, Teban L, Fiebiger M, Binder M, Kittler H. Limitations of dermoscopy in the recognition of melanoma. Arch Dermatol. 2005;141(2):155-160. DOI: 10.1001/archderm.141.2.155. PMID: 15724011. 15. Kittler H, Guitera P, Riedl E, et al. Identification of clinically featureless incipient melanoma using sequential dermoscopy im- aging. Arch Dermatol. 2006;142(9):1113-1119. DOI: 10.1001/ archderm.142.9.1113. PMID: 16982998. 16. Tschandl P, Wiesner T. Advances in the diagnosis of pigmented skin lesions. Br J Dermatol. 2018;178(1):9-11. DOI: 10.1111/ bjd.16109. PMID: 29357612. 4 Review | Dermatol Pract Concept. 2022;12(03):e2022100 17. Marino ML, Carrera C, Marchetti MA, Marghoob AA. Practice Gaps in Dermatology: Melanocytic Lesions and Melanoma. Dermatol Clin. 2016;34(3):353-362. DOI: 10.1016/j.det.2016. 03.003. PMID: 27363893. 18. Steeb T, Wessely A, Niesert AC, et al. Patient Attitude to- wards Videodermatoscopy for the Detection of Skin Cancer: A Cross-Sectional Study. Oncol Res Treat. 2019;42(6):319-325. DOI: 10.1159/000499630. PMID: 30995670. 19. Bevona C, Goggins W, Quinn T, Fullerton J, Tsao H. Cu- taneous melanomas associated with nevi. Arch Dermatol. 2003;139(12):1620-1624; discussion 1624. DOI: 10.1001/arch- derm.139.12.1620. PMID: 14676081. 20. Salerni G, Terán T, Puig S, et al. Meta-analysis of digital dermos- copy follow-up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society. J Eur Acad Dermatol Venereol. 2013;27(7):805-814. DOI: 10.1111/jdv.12032. PMID: 23181611. 21. Argenziano G, Mordente I, Ferrara G, Sgambato A, Annese P, Zalaudek I. Dermoscopic monitoring of melanocytic skin le- sions: clinical outcome and patient compliance vary according to follow-up protocols. Br J Dermatol. 2008;159(2):331-336. DOI: 10.1111/j.1365-2133.2008.08649.x. PMID: 18510663. 22. Gadens GA. Lack of compliance: a challenge for digital dermos- copy follow-up. An Bras Dermatol. 2014;89(2):242-244. DOI: 10.1590/abd1806-4841.20142547. PMID: 24770499. PMCID: PMC4008053. 23. Madigan LM, Treyger G, Kohen LL. Compliance with se- rial dermoscopic monitoring: An academic perspective. J Am Acad Dermatol. 2016;75(6):1171-1175. DOI: 10.1016/j. jaad.2016.07.012. PMID: 27665211. 24. Seidenari S, Ferrari C, Borsari S, et al. Dermoscopy of small melanomas: just miniaturized dermoscopy? Br J Dermatol. 2014;171(5):1006-1013. DOI: 10.1111/bjd.12542. PMID: 23909951. 25. Lallas A, Longo C, Manfredini M, et al. Accuracy of Dermo- scopic Criteria for the Diagnosis of Melanoma In Situ. JAMA Dermatol. 2018;154(4):414-419. DOI: 10.1001/jamaderma- tol.2017.6447. PMID: 29466542. PMCID: PMC5876885. 26. Rodríguez-Lomba E, Lozano-Masdemont B, Nieto-Benito LM, Hernández de la Torre E, Suárez-Fernández R, Avilés-Izquierdo JA. Dermoscopic Predictors of Tumor Thickness in Cutane- ous Melanoma: A Retrospective Analysis of 245 Melanomas. Dermatol Pract Concept. 2021;11(3):e2021059. DOI: 10.5826/ dpc.1103a59. PMID: 34123562. PMCID: PMC8172007. 27. Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of me- lanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol. 2000;43(3):467- 476. DOI: 10.1067/mjd.2000.107504. PMID: 10954658. 28. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCar- thy WH. Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol. 2001;137(12):1583-1589. DOI: 10.1001/archderm.137.12.1583. PMID: 11735708. 29. Faries MB, Wanek LA, Elashoff D, Wright BE, Morton DL. Predictors of occult nodal metastasis in patients with thin mel- anoma. Arch Surg. 2010;145(2):137-142. DOI: 10.1001/arch- surg.2009.271. PMID: 20157080. PMCID: PMC2880665. 30. Karakousis G, Gimotty PA, Bartlett EK, et al. Thin Melanoma with Nodal Involvement: Analysis of Demographic, Pathologic, and Treatment Factors with Regard to Prognosis. Ann Surg Oncol. 2017;24(4):952-959. DOI: 10.1245/s10434-016-5646-9. PMID: 27807729. PMCID: PMC5555768. 31. Richetta AG, Valentini V, Marraffa F, et al. Metastases risk in thin cutaneous melanoma: prognostic value of clinical-patho- logic characteristics and mutation profile. Oncotarget. 2018;9(63):32173-32181. DOI: 10.18632/oncotarget.25864. PMID: 30181807. PMCID: PMC6114949. 32. Maurichi A, Miceli R, Eriksson H, et al. Factors Affecting Sentinel Node Metastasis in Thin (T1) Cutaneous Melanomas: Develop- ment and External Validation of a Predictive Nomogram. J Clin Oncol. 2020;38(14):1591-1601. DOI: 10.1200/JCO.19.01902. PMID: 32167862. PMCID: PMC7213590. 33. Salerni G, Carrera C, Lovatto L, et al. Benefits of total body pho- tography 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;67(1):e17-e27. DOI: 10.1016/j.jaad.2011.04.008. PMID: 21683472. PMCID: PMC3215791. 34. Valcuende Cavero F, Iglesias Valcuende M, Diaz Diaz RM. Informed consent in dermatology: an update. Actas Dermosi- filiogr. 2014;105(6):569-573. DOI: 10.1016/j.ad.2013.11.009. PMID: 24661949. 35. Di Paolo M, Gori F, Papi L, Turillazzi E. A review and analysis of new Italian law 219/2017: ‘provisions for informed consent and advance directives treatment’. BMC Med Ethics. 2019;20(1):17. DOI: 10.1186/s12910-019-0353-2. PMID: 30832644. PMCID: PMC6399822. 36. Goldberg DJ. Legal issues in dermatology: informed consent, complications and medical malpractice. Semin Cutan Med Surg. 2007;26(1):2-5. DOI: 10.1016/j.sder.2006.12.001. PMID: 17349556. 37. Tribunale di Genova, II Sezione Civile, Sentenza n. 939/2017, pubblicata il 04.04.2017, RG 6659/2014, - Genua Tribunal, II Civil Section, pronunciation n. 939/2017, published on 2017, 04.04, RG 6659/2014. Available from: https://dokumen.tips/ documents/il-tribunale-di-genova-rivista-sentenza-n-9392017- pubbl-il-04042017-rg.html?page=1 38. Milam EC, Leger MC. Use of medical photography among dermatologists: a nationwide online survey study. J Eur Acad Dermatol Venereol. 2018;32(10):1804-1809. DOI: 10.1111/ jdv.14839. PMID: 29405432. 39. Rimoin L, Haberle S, DeLong Aspey L, Grant-Kels JM, Stoff B. Informed Consent, Use, and Storage of Digital Photography Among Mohs Surgeons in the United States. Dermatol Surg. 2016;42(3):305-309. DOI: 10.1097/DSS.0000000000000634. PMID: 26863597. 40. Lin MJ, Mar V, McLean C, Kelly JW. An objective measure of growth rate using partial biopsy specimens of melano- mas that were initially misdiagnosed. J Am Acad Dermatol. 2014;71(4):691-697. DOI: 10.1016/j.jaad.2014.04.068. PMID: 24976443. 41. Megaris A, Lallas A, Bagolini LP, et al. Dermoscopy features of melanomas with a diameter up to 5 mm (micromelanomas): A retrospective study. J Am Acad Dermatol. 2020;83(4):1160- 1161. DOI: 10.1016/j.jaad.2020.04.006. PMID: 32289392. 42. Kittler H, Binder M. Risks and benefits of sequential imaging of melanocytic skin lesions in patients with multiple atypical nevi. Arch Dermatol. 2001;137(12):1590-1595. DOI: 10.1001/arch- derm.137.12.1590. PMID: 11735709.