Utility of Lesion Diameter in the Clinical Diagnosis of ...


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  1. 1. STUDY Utility of Lesion Diameter in the Clinical Diagnosis of Cutaneous Melanoma Naheed R. Abbasi, MPH, MD; Molly Yancovitz, MD; Dina Gutkowicz-Krusin, PhD; Katherine S. Panageas, DrPH; Martin C. Mihm, MD; Paul Googe, MD; Roy King, MD; Victor Prieto, MD; Iman Osman, MD; Robert J. Friedman, MD; Darrell S. Rigel, MD; Alfred W. Kopf, MD; David Polsky, MD, PhD Objective: To determine the utility of the current di- ameter criterion of larger than 6 mm of the ABCDE ac- ronym for the early diagnosis of cutaneous melanoma. Design: Cohort study. Setting: Dermatology hospital-based clinics and com- munity practice offices. Patients: A total of 1323 patients undergoing skin biop- sies of 1657 pigmented lesions suggestive of melanoma. Main Outcome Measure: The maximum lesion di- mension (diameter) of each skin lesion was calculated before biopsy using a novel computerized skin imaging system. Results: Of 1657 biopsied lesions, 853 (51.5%) were 6 mm or smaller in diameter. Invasive melanomas were diagnosed in 13 of 853 lesions (1.5%) that were 6 mm or smaller in diameter and in 41 of 804 lesions (5.1%) that were larger than 6 mm in diameter. In situ melano- mas were diagnosed in 22 of 853 lesions (2.6%) that were 6 mm or smaller in diameter and in 62 of 804 lesions (7.7%) that were larger than 6 mm in diameter. Conclusion: The diameter guideline of larger than 6 mm provides a useful parameter for physicians and should continue to be used in combination with the A, B, C, and E criteria previously established in the selection of atypi- cal lesions for skin biopsy. Arch Dermatol. 2008;144(4):469-474 I N 1985,SEVERAL OF US DEVISED THE ABCD criteria for melanoma screening1 to facilitate the early di- agnosis of cutaneous melanoma. The ABCD criteria are evidence- basedguidelinesestablishedtoremindphy- sicians that Asymmetry, Border irregular- ity, Color variegation, and Diameter larger than 6 mm are features characteristic of melanoma.Inrecentpublications,ourgroup reviewed evidence supporting the concept of lesion change in the diagnosis of cuta- neous melanoma and formally recom- mended expansion of the ABCD criteria to include an E criterion for Evolution.2,3 Rap- idly growing melanomas, especially nodu- lar melanomas, frequently lack ABCD fea- tures.4,5 Thus, the addition of an E criterion greatly aids in the diagnosis of banal- appearing melanomas whose sole but criti- cal concerning clinical feature is that of growth or change over time.5 As the incidence of melanoma contin- ues to increase worldwide,6 the ABCDE cri- teria remain important to public educa- tion in the early recognition of melanoma. An important challenge to the ABCDE cri- teria has been the recent recognition of small melanomas (Յ6 mm in diameter). Several authors7-11 have described such tu- mors in US, Australian, Italian, and Is- raeli patient cohorts. Our 2004 publica- tion, which reviewed all available small melanoma data from patient cohorts of more than 30 persons, concluded that small-diameter melanomas likely com- pose 3% to 14% of all cutaneous melano- mas but rarely result in recurrence, me- tastasis, or death.2,7-12 Nevertheless, the existence of small-diameter melanomas complicates the evaluation of pigmented lesions suggestive of melanoma. Some au- thors7,9 have argued that a D criterion of larger than 6 mm may be misleading be- cause strict adherence to this guideline will result in the failure to biopsy small mela- nomas. Yet others13 point out that more than 99% of atypical melanocytic lesions biopsied by dermatologists are benign. Clearly, additional data are needed to help physicians balance their desire to biopsy atypical pigmented lesions suggestive of See also pages 476 and 538 Author Affiliations: Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York (Drs Abbasi, Yancovitz, Osman, Friedman, Rigel, Kopf, and Polsky), Electro-Optical Sciences Inc, Irvington (Dr Gutkowicz- Krusin), and Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Panageas); Department of Dermatology, Harvard Medical School, Boston, Massachusetts (Dr Mihm); Knoxville Dermatopathology Laboratory, Knoxville, Tennessee (Drs Googe and King); and The University of Texas M. D. Anderson Cancer Center, Houston (Dr Prieto). (REPRINTED) ARCH DERMATOL/VOL 144 (NO. 4), APR 2008 WWW.ARCHDERMATOL.COM 469 ©2008 American Medical Association. All rights reserved. on November 10, 2010www.archdermatol.comDownloaded from
  2. 2. melanoma with the knowledge that most pigmented skin lesions are benign. To our knowledge, no large studies have described the relationship between in vivo lesion diameter and fre- quency of melanoma among lesions biopsied because of concern about melanoma. The main purpose of our study was to answer the question of whether the D criterion of the current ABCDE criteria should be adjusted down- ward (eg, changing the diameter guideline from 6 to 5 mm) in light of the known existence of small-diameter melanomas. Our study elucidates the relationship be- tween lesion diameter and the diagnosis of melanoma among 1657 consecutive atypical pigmented skin le- sions biopsied by dermatologists. METHODS Our group, in collaboration with investigators at Electro- Optical Sciences Inc (EOS), collected and analyzed diameter measurements and histopathologic diagnoses of 1657 consecu- tive pigmented skin lesions in 1323 patients accrued as part of the second phase of the multicenter MelaFind Study.14 Pa- tients of any age, race, ethnicity, or sex with pigmented le- sions suggestive of melanoma and requiring skin biopsy were eligible for enrollment in the study. The specific reason for bi- opsy of each lesion was not recorded; however, lesions sug- gestive of melanoma were those that generally possessed 1 or more of the ABCDE features or were of particular concern to the patient or physician. Physicians who participated in the study were composed of a group of dermatologists in both academic and community prac- tices (see “Clinical Principal Investigators”) across the United States. They were chosen for their particular interest in the di- agnosis of pigmented skin lesions and/or a substantial volume of patients potentially requiring skin biopsies. Of the 1657 le- sions, 44.7% were examined in academic practices and 55.3% were examined in community practices. The proportion of mela- nomas examined in academic practices was 7.6%, vs 8.9% ex- amined in community practices. The observed differences were small and not statistically significant (P=.32). Institutional re- view board approvals were obtained for all participating sites, and all patients signed written informed consent at enroll- ment. MelaFind is an experimental computerized skin imaging sys- tem devised by EOS to diagnose melanoma.14,15 The probe, just slightly larger than a cordless telephone, acquires digital im- ages of pigmented skin lesions illuminated by different spec- tral bands of light from visible to near infrared. It automati- cally extracts pertinent data for image analysis by the EOS central computer. In addition, EOS is developing an image analysis al- gorithm to serve as an aid for physicians in the diagnosis of mela- noma. The images and histopathologic diagnoses collected in this study were part of that development effort; hence, no di- agnostic information was provided to the physicians from the MelaFind system at any time in the study. For this article, the function of the system was to accurately measure the in vivo diameters of pigmented lesions deemed by dermatologists to be potentially malignant. Diameter measurement is not incor- porated into the diagnostic computer algorithm being devel- oped to identify lesions as benign or malignant. The maxi- mum diameter is defined as the longest distance between 2 points located on the lesion border. Diameter measurements are re- portedtohundredthsofmillimeters.Imagesegmentationisbased on lesion images obtained at wavelengths of 430 and 500 nm. A proprietary mathematical operation automatically defines which pixels are in the lesion and which are not. Additional methodologic details can be found in 2 previous publica- tions.14,15 All lesions in the cohort were biopsied, and histo- pathologic diagnoses were independently rendered by 2 der- matopathologists (one diagnosis was rendered by 1 of us [M.C.M.] for all lesions and the second diagnosis was ren- dered by 1 of 3 of us [P.G., R.K., or V.P.]) without previous discussion of diagnostic features. To resolve occasional differ- ences in diagnoses between the 2 dermatopathologists, con- sultation by a third dermatopathologist (1 of 3 of us [P.G., R.K., or V.P.]) was obtained. Such differences occurred in only 6% of cases, a proportion that compares favorably to the consid- erable disagreement reported across the literature for diagno- sis of melanocytic lesions by dermatopathologists.16-18 At initiation of this analysis, 1657 lesions had been ac- crued and appraised in the study. We sorted these lesions into categories based on diameter and diagnosis. In our analysis, we were particularly interested in quantifying the number and pro- portion of melanomas among this cohort of clinically suspi- cious pigmented lesions and among its smaller subset of me- lanocytic neoplasms (n=1380). Sensitivity (true positive/ [true positiveϩfalse negative]) and specificity (true negative/ [false positiveϩtrue negative]) were calculated for various cut points for the diagnosis of melanoma (invasive and in situ). The following definitions were used: true positive was defined as mela- nomas with diameters greater than the cutoff value, false posi- tive was defined as nonmelanomas with diameters greater than the cutoff value, true negative was defined as nonmelanomas Table 1. Distribution of Pigmented Skin Lesions in the Study Cohort Lesion Type No. (%) of 1657 Lesions Dysplastic nevi 1016 (61.3) Other nevi 226 (13.6) Invasive melanoma 54 (3.3) Melanoma in situ 84 (5.1) Seborrheic keratosis 120 (7.2) Other 157 (9.5) 1 mm Figure 1. Representative MelaFind image. The periphery of the lesion, as identified by the image analysis software, is shown in green. Diameter measurements were based on the lesion periphery. A ruler has been added to the image to demonstrate the scale of the image. (REPRINTED) ARCH DERMATOL/VOL 144 (NO. 4), APR 2008 WWW.ARCHDERMATOL.COM 470 ©2008 American Medical Association. All rights reserved. on November 10, 2010www.archdermatol.comDownloaded from
  3. 3. with diameters less than the cutoff value, and false negative was defined as melanomas with diameters less than the cutoff value. A receiver operating characteristic (ROC) curve was esti- mated nonparametrically to visually summarize the accuracy of the predictions.19 The unit of analysis throughout the study was pigmented lesion(s), not individual patients. In patients with more than 1 clinically suspicious pigmented lesion, each was assessed separately with regard to its diameter and diag- nosis. In this study the patients contributed 1.25 lesions per patient. When we accounted for multiple lesions per patient, the area under the curve for the ROC curve was exactly the same (0.68; 95% confidence interval, 0.63-0.73) as when we used the regular nonclustered methods.20 RESULTS A total of 852 women and 805 men participated in the study. The mean age of the women was 43.5 years (me- dian age, 42 years); the mean age of the men was 50 years (median age, 51 years). Among the 1657 lesions under study, 138 (8.3%) were histologically diagnosed as mela- noma, including invasive (n=54) and in situ (n=84) le- sions. Other diagnoses included dysplastic nevi (n=1016), othermelanocyticnevi(eg,Spitzandcongenital)(n=226), and other nonmelanocytic lesions (eg, seborrheic kera- tosis) (n=277) (Table 1). Eight hundred four lesions (48.5%) were greater than 6 mm in diameter, and 853 (51.5%) were 6 mm in di- ameter or less. A representative MelaFind image used to calculate lesion diameter is shown in Figure 1. Within each 1-mm diameter range from 2.01 to 6.00 mm, the proportion of melanomas did not vary significantly, re- maining stable at 3.6% to 4.5% (Table 2 and Figure 2). However, we observed a nearly 100% increase in the pro- portion of melanomas when comparing the 5.01- to 6.00-mm category (4.3%) to the 6.01- to 7.00-mm cat- egory (8.3%). Among lesions 6.01 mm in diameter or larger, the proportion of melanomas ranged from 8.1% to 21.9%, roughly increasing as lesion diameters in- Table 2. Proportion of Melanomas Among All Lesions Stratified by Lesion Diameter Diameter, mm Total Lesionsa Invasive Melanomasb In Situ Melanomasb Total Melanomasb 1.01-2.00 1 (0.1) 0 0 0 2.01-3.00 94 (5.7) 2 (2.1) 2 (2.1) 4 (4.3) 3.01-4.00 220 (13.3) 1 (0.5) 9 (4.1) 10 (4.5) 4.01-5.00 281 (17.0) 5 (1.8) 5 (1.8) 10 (3.6) 5.01-6.00 257 (15.5) 5 (1.9) 6 (2.3) 11 (4.3) 6.01-7.00 192 (11.6) 7 (3.6) 9 (4.7) 16 (8.3) 7.01-8.00 186 (11.2) 4 (2.2) 11 (5.9) 15 (8.1) 8.01-9.00 127 (7.7) 4 (3.1) 12 (9.4) 16 (12.6) 9.01-10.00 89 (5.4) 4 (4.5) 6 (6.7) 10 (11.2) Ͼ 10.00 210 (12.7) 22 (10.5) 24 (11.4) 46 (21.9) Total No. (%)a 1657 54 (3.3) 84 (5.1) 138 (8.3) aData are given as number (percentage) of the 1657 total lesions. bData are given as number (percentage) of total lesions in each diameter category. 25.0 20.0 15.0 10.0 5.0 0 2.01-3.00 3.01-4.00 4.01-5.00 5.01-6.00 6.01-7.00 7.01-8.00 8.01-9.00 9.01-10.00 >10.00 Diameter, mm Melanoma,% In situ lesions Invasive lesions 4.3% 4.5% 3.6% 4.3% 8.3% 8.1% 12.6% 11.2% 21.9% Figure 2. Proportion of melanomas among all lesions. Each category on the x-axis represents a range of lesion diameters. The proportion of melanomas among biopsied lesions within these ranges is expressed as percentages indicated above each bar and on the y-axis. A break point in the proportion of melanomas among biopsied lesions is apparent at diameters larger than 6.0 mm. (REPRINTED) ARCH DERMATOL/VOL 144 (NO. 4), APR 2008 WWW.ARCHDERMATOL.COM 471 ©2008 American Medical Association. All rights reserved. on November 10, 2010www.archdermatol.comDownloaded from
  4. 4. creased. We analyzed the proportions of invasive and in situ melanomas separately and found that invasive mela- nomas were diagnosed in 13 of 853 lesions (1.5%) that were 6 mm in diameter or smaller and in 41 of 804 le- sions (5.1%) that were larger than 6 mm in diameter, whereas in situ melanomas were diagnosed in 22 of 853 lesions (2.6%) that were 6 mm in diameter or smaller and in 62 of 804 lesions (7.7%) that were larger than 6 mm in diameter. Recognizing the importance of Breslow thick- ness to prognosis in melanoma, we also analyzed mean tumor thickness for invasive melanomas in each inter- val listed in Table 2 but could not identify trends or a reasonable cutoff based on tumor thickness (data not shown). We were also interested in determining whether the striking increase in melanoma proportion among le- sions greater than 6 mm would also be observed when the analysis was restricted only to melanocytic neo- plasms (nevi and melanoma). Table 3 reports the fre- quency of melanomas vs nevi of various diameters. Mela- nomas comprise in situ and invasive lesions; the remaining melanocytic neoplasms comprise dysplastic nevi and other nevi, which include Spitz nevi, congenital nevi, and blue nevi. We again observed a 100% increase in the propor- tion of melanomas among the 6.01- to 7.00-mm cat- egory (9.9%) vs the 5.01- to 6.00-mm category (4.9%). There was a generally constant proportion of melano- mas (4.0%-5.3%) among lesions 6 mm in diameter or smaller but a significantly larger and increasing propor- tion of melanomas (9.9%-28.6%) among lesions with di- ameters greater than 6 mm. Although it was not the intent of this study to ana- lyze the diameter criterion as a stand-alone screening test for melanoma, we performed an ROC analysis to assess the clinical utility of various diameter measurements in the diagnosis of melanoma. Specifically, we calculated the sensitivity and specificity of diameters of 4, 5, 6, 7, 8, 9, and 10 mm for the diagnosis of melanoma (Table 4). As diameter increased from 4 to 10 mm, sensitivity de- creased for the diagnosis of melanoma and specificity in- creased. The 6-mm diameter criterion yielded a sensi- tivity of 75% and a specificity of 54%. In comparison, a 5-mm cutoff had a sensitivity of 83% and a specificity of 38% and a 7-mm cutoff had a sensitivity of 63% and a specificity of 65%. COMMENT Our study design is unique in several ways. First, we used computer technology to measure the diameters of pig- mented lesions with great accuracy and precision, thus considerably reducing the possibility of interobserver vari- ability introduced by human measurements of skin le- sions. Second, we measured pigmented lesions in vivo and reported biopsy results of all lesions studied. Third, we studied a large cohort of suspicious but mostly be- nign lesions to better understand the frequency of mela- nomas among clinically suspicious atypical pigmented lesions. With the exception of 1 study,9 other au- thors7-11,21 have focused their attention on populations of ex vivo biopsy-confirmed small melanomas. Ex vivo specimen measurement may result in underestimation of lesion diameter by as much as 20%.22,23 The rigor of our study design allows much greater insight into the re- lationship between lesion diameter and diagnosis than any previous study by using accurate lesion measure- ments rather than the rough estimates not uncommon in dermatologic practice. Table 3. Proportions of Melanoma, Dysplastic Nevi, and Other Nevi Among 1380 Melanocytic Neoplasms Stratified by Lesion Diameter Diameter, mm Melanomaa Dysplastic Nevia Other Nevia Total Lesionsb 1.01-2.00 0 0 1 (100) 1 (0.1) 2.01-3.00 4 (5.2) 56 (72.7) 17 (22.1) 77 (5.6) 3.01-4.00 10 (5.3) 144 (76.2) 35 (18.5) 189 (13.7) 4.01-5.00 10 (4.0) 202 (80.5) 39 (15.5) 251 (18.2) 5.01-6.00 11 (4.9) 183 (81.0) 32 (14.2) 226 (16.4) 6.01-7.00 16 (9.9) 112 (69.1) 34 (21.0) 162 (11.7) 7.01-8.00 15 (10.6) 107 (75.9) 19 (13.5) 141 (10.2) 8.01-9.00 16 (16.2) 68 (68.7) 15 (15.2) 99 (7.2) 9.01-10.00 10 (13.7) 54 (74.0) 9 (12.3) 73 (5.3) Ͼ 10.00 46 (28.6) 90 (55.9) 25 (15.5) 161 (11.7) Total No. (%) 138 (10.0) 1016 (73.6) 226 (16.4) 1380 aData are given as number (percentage) of total lesions for the indicated diameter category. bData are given as number (percentage) of the 1380 total lesions. Table 4. Sensitivity and Specificity of Selected Lesion Diameters Derived From Receiver Operating Characteristic Curve Analysis Cutoff, mm Sensitivity (n=138)a Specificity (n=1519)a Ͼ 4.0 90 (84-94) [124] 20 (18-22) [301] Ͼ 5.0 83 (75-88) [114] 38 (35-40) [572] Ͼ 6.0 75 (67-81) [103] 54 (51-57) [818] Ͼ 7.0 63 (55-71) [87] 65 (63-68) [994] Ͼ 8.0 52 (44-61) [72] 77 (74-79) [1165] Ͼ 9.0 41 (33-49) [56] 84 (82-86) [1276] Ͼ 10.0 33 (26-42) [46] 89 (87-91) [1335] aData are given as percentage (95% confidence interval) [number of lesions]. (REPRINTED) ARCH DERMATOL/VOL 144 (NO. 4), APR 2008 WWW.ARCHDERMATOL.COM 472 ©2008 American Medical Association. All rights reserved. on November 10, 2010www.archdermatol.comDownloaded from
  5. 5. The goal of this study was to determine if a diameter measurement of greater than 6 mm was still a useful guide- line in the diagnosis of melanoma. Ideally, we would want to determine the frequency of melanomas among all pig- mented skin lesions; however, this would be exceed- ingly difficult. Melanoma is still a relatively rare tumor, and the average adult patient has between 11 and 50 nevi, with 5% of patients having at least 1 atypical nevus.24 Thus, to conduct a clinical trial to calculate the frequency of melanomas among all pigmented skin lesions would re- quire the removal and histopathologic diagnosis of all pig- mented skin lesions on each patient, a nearly impos- sible and extraordinarily expensive task. The present study took advantage of a cohort of suspicious clinically atypi- cal lesions that were biopsied primarily because of a con- cern for melanoma. This study design would likely en- rich the cohort with melanomas compared with a study that biopsied all pigmented lesions, yet even within this more selective cohort, the rate of melanoma was low. Al- though we do not know how many melanomas were missed by this group of physicians, the physicians who enrolled patients into the MelaFind study were experi- enced dermatologists who are, arguably, less likely to miss many malignant lesions or to select benign lesions for further appraisal than their less specialized colleagues. Nevertheless, the fact that most lesions biopsied in the MelaFind Study (853 of 1657) were less than 6 mm in diameter suggests a substantial concern among physi- cians not to miss small-diameter melanomas. Despite the inherent selection bias of our study design, our data pro- vide strong support for the idea that small melanomas are rare, even among a cohort of clinically atypical pig- mented lesions that experienced physicians may excise. We recommend that a diameter criterion of larger than 6 mm remain a part of the ABCDE criteria. Lesion diam- eter greater than 6 mm seems to be a significant indica- tor of increased suspicion for melanoma because our data reveal a significant increase in the proportion of mela- nomas among lesions larger than 6 mm when compared with lesions 6 mm or smaller (Figure 2 and Table 2). In addition, data from the ROC analysis suggest that down- ward revision of the diameter criterion to 5 mm would result in a significant loss of specificity. Because more than 50% of all suspicious lesions biopsied in this study were 6 mm or smaller yet only 1.5% of those were invasive melanoma and 2.6% were in situ melanoma, it seems that many biopsies are being performed on small lesions based on their A, B, C, and E characteristics, with a low speci- ficity for detecting melanoma. It is likely that lowering the D criterion to 5 mm would only further decrease the specificity of such biopsies. For pigmented lesions with diameters that measure 6 mm or less, we believe that the use of the ABCDE2 cri- teria in combination can be an effective management strat- egy. Specifically, identifying lesions that possess more atypical features (eg, A, B, C, or E) is likely to be more specific for melanoma. Thomas et al25 demonstrated that specificity for the diagnosis of melanoma increases mark- edly as the number of ABCDE criteria present in a pig- mented lesion increase from 1 or more (36%) to 4 or more (94%); however, there is a concomitant decrease in sen- sitivity from 97% to 54%, respectively. Our ROC analy- sis indicates that a diameter criterion of larger than 6 mm is not sensitive or specific enough to serve as a stand- alone screening test for melanoma, consistent with the observations of Thomas et al. Unfortunately, in the pres- ent study we were unable to examine the utility of the A, B, C, or E criteria or combinations thereof; however, Thomas et al found that horizontal enlargement had the greatest combination of sensitivity and specificity for mela- noma, followed by the D criterion, so it may be espe- cially helpful to consider lesional evolution (E), such as horizontal enlargement, in lesions 6 mm or smaller. The significant increase in the proportion of melano- mas among lesions greater than 6 mm in diameter sug- gests that a lesion size of 6 mm may have biological sig- nificance.Thecurrenttheoryregardingcellularsenescence in melanocytic nevi26,27 predicts that nevus cells un- dergo a certain number of cell divisions, after which cel- lular mechanisms of long-term growth arrest (eg, tumor suppressor genes) halt proliferation. Loss of these growth arrest mechanisms is common in melanoma28 ; however, much additional work is needed to correlate the fre- quency of these biological alterations with lesion size. In conclusion, the present study reaffirms that a diam- eter criterion of larger than 6 mm is a useful guideline for the early detection of cutaneous melanoma. We do not rec- ommend downward revision of the D criterion at this time. In the United States, rates of melanoma and nonmela- noma skin cancers have markedly increased, and skin bi- opsy rates have more than doubled in 20 years.29 In an era thatdemandsgreaterdatatosupportclinicaldecisionmak- ing, the ABCDE criteria are valuable evidence-based guide- lines to aid physicians in decisions regarding the biopsy of pigmented lesions of the skin. Accepted for Publication: June 20, 2007. Correspondence: David Polsky, MD, PhD, Ronald O. Per- elman Department of Dermatology, New York Univer- sity School of Medicine, 550 First Ave, Room H-100, New York, NY 10016 (David.Polsky@nyumc.org). Author Contributions: Dr Polsky had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study con- cept and design: Abbasi, Prieto, Osman, Friedman, Rigel, Kopf, and Polsky. Acquisition of data: Abbasi, Gutkowicz- Krusin, Mihm, Googe, King, and Prieto. Analysis and interpretation of data: Abbasi, Yancovitz, Panageas, Prieto, Osman, and Polsky. Drafting of the manuscript: Abbasi, Prieto, and Polsky. Critical revision of the manuscript for importantintellectualcontent:Abbasi,Yancovitz,Gutkowicz- Krusin, Panageas, Mihm, Googe, King, Prieto, Osman, Friedman, Rigel, Kopf, and Polsky. Statistical analysis: Panageas. Administrative and technical support: Gutkowicz- Krusin. Study supervision: Osman and Polsky. Financial Disclosure: Dr Gutkowicz-Krusin is an em- ployee of EOS; Drs Mihm, Googe, King, and Prieto are dermatopathologists for the MelaFind Study, sponsored by EOS; Dr Friedman is a consultant for and share- holder in EOS; Dr Rigel is a consultant for EOS; Drs Kopf and Polsky are investigators for the MelaFind Study spon- sored by EOS; and Dr Polsky is a consultant for EOS. Role of the Sponsor: The data were extracted from a clini- cal study sponsored by EOS; EOS provided data to the (REPRINTED) ARCH DERMATOL/VOL 144 (NO. 4), APR 2008 WWW.ARCHDERMATOL.COM 473 ©2008 American Medical Association. All rights reserved. on November 10, 2010www.archdermatol.comDownloaded from
  6. 6. research team but had no role in study design, data analy- sis, or data interpretation. Clinical Principal Investigators: Jeffrey Callen, MD, Uni- versity of Louisville, Louisville, Kentucky; Armand Cognetta, MD, Dermatology Associates of Tallahassee, Tallahassee, Florida; Caron Grin, MD, University of Con- necticut, Hartford; Kenneth Gross, MD, Skin Surgery Medical Group, San Diego, California; Allan Halpern, MD, Memorial Sloan-Kettering Cancer Center, New York, New York; Peter Lee, MD, University of Minnesota, Minne- apolis; Seth Lerner, MD, Adult and Pediatric Dermatol- ogy Specialists, Trumbull, Connecticut; Norman Levine, MD, University of Arizona Health Sciences Center, Tuc- son; Gary Monheit, MD, Total Skin and Beauty Derma- tology, Birmingham, Alabama; Gary Peck, MD, Wash- ington Cancer Institute, Washington, DC; Harold Rabinovitz, MD, Skin & Cancer Associates, Plantation, Florida; Jennifer Schwartz, MD, University of Michigan, Ann Arbor; Nancy Thomas, MD, PhD, University of North Carolina, Chapel Hill; Yardy Tse, MD, Dermatology As- sociates of San Diego, Encinitas, California. 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