Catch More, Cut Less. A Breakthrough In Melanoma Detection

by Dr. Maral Skelsey, Director of the Dermatologic Surgery Center of Washington and Director of the Mohs Surgery Unit at Georgetown University | May 30, 2018

As I was about to open the door of the exam room, my nurse handed me a box of tissues. “Take these to the patient,” she said. “ She’s just about used up the box that’s in there.”

I reviewed the chart for the 36 y/o woman with a history of melanoma in situ at age 28 and multiple dysplastic nevi.

Lisette, a  blonde, blue-eyed lawyer who had moved from the mid-west to join the Justice Department, was quietly dabbing tears. “I’m sorry I’m a such a mess, “ she sobbed. “ I just dread more scars. Here are my records.” She handed me a thick, manila envelope. “  I haven’t been checked in 3 years but my fiancé made me promise that I’d come in. But I know you’re going to want to take some moles off and I can’t deal with  the needles or the scars.”  At that she began weeping.

I looked through the records: In addition to the melanoma in situ, she’d undergone 13 excisions of dysplastic nevi. No family history of melanoma, but weekly indoor tanning during college and law school.

When I examined her, in between the numerous scars on her back, arms, chest and legs, she has approximately 100 nevi that I evaluated with a dermatoscope.  Two on the chest were significantly darker than the others and exhibited an irregular pigment network, one of the hallmarks of atypia in dermoscopy.

“I knew you’d want to take those off, “ she said. They’ve changed but the scars are going to look terrible when I’m wearing my wedding gown!”

A couple of years ago I would have dreaded delivering the bad news that she needed biopsies. Now I could explain that a biopsy could be performed without a blade and without any needles.

She looked at me dubiously when I explained that a piece of tape applied 4 times to a single lesion could retrieve a sufficient number of cells to perform a sophisticated RNA study.

Watching me carefully as I applied the clear stickers to each mole and then affixed them on the card, she let out a huge sigh of relief when I was finished. “That’s seriously all there is to it?” Her face was transformed with an enormous grin.

I carefully explained that we’d get results in a week and that we’d have to remove a mole that expressed the genes. But she was still smiling as she left, laughing, “ this is the first time I’ve left the dermatologist’s office without a couple of bandages. I’m keeping my fingers crossed  that’s all you’ll have to do and I’ll see you in 6 months!”

Happily for Lisette, neither lesion expressed LINC or PRAME and instead of waiting another 3 years for a full body exam, she returns every 6 months like clockwork.

The bladeless biopsy has been an enormous relief for patient like Lisette, reducing the number of unnecessary biopsies. I have also found it very helpful- possibly even life-saving for patients whose pigmented lesions are  only slightly atypical and in cosmetically sensitive locations.

“Alison,” a  52 y/o woman with no prior history of melanoma, came to me the day before she was leaving for a 3 week trip to Europe. She pointed to a light-tan/brown spot on her cheek bone that was the size of a quarter. “ I think it’s getting a little bigger and I wanted to check it out before I go away.”

She had fair skin and a lot of freckles. This spot wasn’t much darker than the others. On dermoscopy it had a moth-eaten border, relatively regular follicular areas and only mild asymmetry. Given the  very visible location, in the past I might have suggested taking photos and “watching and  waiting” for 3 months.  I didn’t want her European photo album filled with pictures of her with a bandage on her face. On the other hand, it was growing and with a non-invasive option I didn’t have to wait.

Unfortunately for Alison, and somewhat surprising for me, the lesion was Dermtech positive for both LINC and PRAME. The subsequent biopsy demonstrated an invasive malignant melanoma and I am convinced that diagnosis was made earlier because of the availability of non-invasive gene expression profiling.

In my practice we are excited to be able offer an alternative to the surgical biopsy with DermTech, a “bladeless biopsy.”  This cutting edge technology gives us the ability to test the cells of a suspicious spot without actually cutting the skin or leaving a scar.  The DermTech test is able to detect even the earliest genetic changes that indicate whether a mole or other pigmented growth is at high risk for melanoma.

Melanoma awareness month provides an excellent opportunity to discuss the importance of regular skin checks. When melanoma is diagnosed and treated early, cure rates are very high.  On the other hand, melanoma can be deadly if it is not detected in time. Check your skin regularly and watch for any changes in your moles. Get an annual skin check with a dermatologist and alert them to any new or changing spots on your skin.

Dr. Maral Skelsey, Director of the Dermatologic Surgery Center of Washington and Director of the Mohs Surgery Unit at Georgetown University where she is a Clinical Associate Professor.