Nonpigmented Lesions Research Articles

Histopathological atlas and proposed classification for melanocytic lesions in Tyr::NRasQ61K; Cdkn2a−/− transgenic mice

Reference EPFL-ARTICLE-188431doi:10.1111/pcmr.12115View record in Web of Science Record created on 2013-09-09, modified on 2017-05-12

Dermoscopy use by French private practice dermatologists: a nationwide survey

Dermoscopy is now recognized as an essential tool for discriminating melanoma from other pigmented lesions, as corroborated by several robust meta-analyses. Although it is considered to be widely used in European countries, no published data on this topic are available to date, unlike in Australia and the U.S.A. To describe and quantify the use and learning of dermoscopy among French private practice dermatologists. A questionnaire of 19 items regarding demographic characteristics, dermoscopy use and training, and physician's judgment on dermoscopy was mailed to all French private practice dermatologists. Only questionnaires with an answer to the key item, 'Do you use dermoscopy?' were taken into account. Of 3179 mailed questionnaires, 1611 were returned and 1576 were analysable (49·6%). Most respondents declared using dermoscopy (94·6%), using their dermoscope several times a day (82·7%) and/or for the diagnosis of nonpigmented lesions (87·7%). Physicians learned dermoscopy mainly through books (75·8%) and/or conferences (88·6%); 12·8% reported a dedicated university degree. Dermoscopy helps to detect melanoma earlier and to perform fewer biopsies according to 86·6% and 74·6%, respectively. On multivariate analysis, female sex and age under 45 years were significantly associated with higher utilization rate of dermoscopy [odds ratio 1·89, 95% confidence interval (CI) 1·15-3·10; and 2·85, 95% CI 1·14-7·11, respectively]. This is the first published nationwide survey of dermoscopy practice in Europe. Despite potential classification and/or selection bias, the particularly high penetration rate found in our study suggests that dermoscopy is now widely accepted by French private practice dermatologists for the routine management of both pigmented and nonpigmented lesions.

Dermoscopy of Squamous Cell Carcinoma and Keratoacanthoma

OBJECTIVES To characterize dermoscopic criteria of squamous cell carcinoma (SCC) and keratoacanthoma and to compare them with other lesions. DESIGN Observer-masked study of consecutive lesions performed from March 1 through December 31, 2011. SETTING Primary care skin cancer practice in Brisbane, Australia. PARTICIPANTS A total of 186 patients with 206 lesions. MAIN OUTCOME MEASURES Sensitivity, specificity, predictive values, and odds ratios. RESULTS In a retrospective analysis of 60 invasive SCC and 43 keratoacanthoma cases, keratin, surface scale, blood spots, white structureless zones, white circles, and coiled vessels were commonly found in both types of lesions. We reevaluated the significance of these criteria in 206 raised, nonpigmented lesions (32 SCCs, 29 keratoacanthomas, and 145 other lesions). Central keratin was more common in keratoacanthoma than in SCC (51.2% vs 30.0%, P=.03). Keratin had the highest sensitivity for keratoacanthoma and SCC (79%), and white circles had the highest specificity (87%). When keratoacanthoma and SCC were contrasted with basal cell carcinoma, the positive predictive values of keratin and white circles were 92% and 89%, respectively. When SCC and keratoacanthoma were contrasted with actinic keratosis and Bowen disease, the positive predictive value of keratin was 50% and that of white circles was 92%. In a multivariate model, white circles, keratin, and blood spots were independent predictors of SCC and keratoacanthoma. White circles had the highest odds ratio in favor of SCC and keratoacanthoma. The interobserver agreement for white circles was good (0.55; 95% CI, 0.44-0.65). CONCLUSIONS White circles, keratin, and blood spots are useful clues to differentiate SCC and keratoacanthoma from other raised nonpigmented skin lesions by dermoscopy. The significance of these criteria depends on the clinical context.

Unilateral Non-Pigmented Palpebral Conjunctival Lesions Due to Cosmetics Use

A 62-year-old woman with a history of dry eyes was found to have unilateral pedunculated, nonpigmented palpebral conjunctival lesions. Excisional biopsy was performed, and the lesions were studied histopathologically. Microscopic examination of the lesions demonstrated exuberant granulation tissue with a granulomatous foreign body giant cell reaction surrounding pigmented and partially birefringent foreign material. Histopathologic examination of the patient's cosmetics revealed that the pigmented foreign bodies seen on the biopsy specimens were compatible with her mascara and/or eyeliner. While cosmetics have been reported to have ophthalmic sequelae, palpebral lesions such as these have not been reported to the authors' knowledge.

Accuracy of the first step of the dermatoscopic 2-step algorithm for pigmented skin lesions

Objectives:To evaluate the frequency of misclassifications of equivocal pigmented lesions according to the first step of the dermatoscopic 2-step algorithm.Patients and Methods:707 consecutive cases from 553 patients of central Europe and Australia were included in the study. Dermatoscopic images were evaluated in a blinded fashion for the presence of features described in the 2-step algorithm to determine their melanocytic or non-melanocytic origin. Mucosal, genital and non-pigmented lesions were excluded.Results:The sensitivity of the first step was 97.1% for patients from Australia and 96.8% for patients from central Europe. The specificity was 33.6% for Australian patients and 67.9% for European patients. The most common reasons for misclassification were the presence of a pigmented network in a non-melanocytic lesion (n=68, 25.2%) and the absence of dermatoscopic features of melanocytic and non-melanocytic lesions in 69 (25.6%) non-melanocytic lesions.Conclusion:The first step of the dermatoscopic 2-step algorithm, if applied consistently, has high sensitivity but low specificity. Many non-melanocytic lesions, especially solar lentigines and seborrheic keratoses, are wrongly classified as melanocytic. The worse performance of the first step algorithm in Australian patients is probably due to a higher rate of solar lentigines in patients with severely sun-damaged skin.

In Vivo Diagnosis of Melanoma and Nonmelanoma Skin Cancer Using Oblique Incidence Diffuse Reflectance Spectrometry

Early detection and treatment of skin cancer can significantly improve patient outcome. However, present standards for diagnosis require biopsy and histopathologic examinations that are relatively invasive, expensive, and difficult for patients with many early-stage lesions. Here, we show an oblique incidence diffuse reflectance spectroscopic (OIDRS) system that can be used for rapid skin cancer detection in vivo. This system was tested under clinical conditions by obtaining spectra from pigmented and nonpigmented skin lesions, including melanomas, differently staged dysplastic nevi, and common nevi that were validated by standard pathohistologic criteria. For diagnosis of pigmented melanoma, the data obtained achieved 90% sensitivity and specificity for a blinded test set. In a second analysis, we showed that this spectroscopy system can also differentiate nonpigmented basal cell or squamous cell carcinomas from noncancerous skin abnormalities, such as actinic keratoses and seborrheic keratoses, achieving 92% sensitivity and specificity. Taken together, our findings establish how OIDRS can be used to more rapidly and easily diagnose skin cancer in an accurate and automated manner in the clinic.

Clinicopathologic and Immunohistochemical Features of Pigmented Basal Cell Carcinomas of the Eyelids

To describe the clinical and microscopic features of pigmented basal cell carcinomas (pBCC) of the eyelid. Retrospective observational case series collected at one institution. An analysis of clinical records, photographs, and histopathologic characteristics of 257 BCCs with a review of the literature. The frequencies of clinically pigmented, and of microscopically pigmented but clinically nonpigmented, BCCs were determined. Cytochemical stains (Fontana-Masson, Prussian blue) and immunohistochemical probes (S-100, microphthalmia-associated transcription factor [MiTF], HMB-45, MART-1, CK20, synaptophysin, chromogranin, CD1a, Ki-67) were then employed and the findings correlated with the degree of clinical pigmentation. Histopathologically, 13 of 257 cases (5.06%) were found to have pigment; of these 13, 6 (all white patients) had clinically apparent pigmentation (2.33%), either focal or diffuse. Eight of 13 lesions developed on the lower eyelids. All stained positively for melanin but negatively for iron. MiTF highlighted numerous melanocytic nuclei in the tumor lobules, while MART-1 and HMB-45 revealed the dendritic shapes of the entrapped melanocytes. There was a subtotal blockage of melanin transfer to the surrounding basaloid cells. Intralobular S-100-positive cells included CD1a-positive Langerhans cells, while CK20 did not identify any Merkel cells. Only 1 of 6 lesions was uniformly clinically pigmented, whereas the other 5 were only focally brown-black. The clinical pigmentation was imparted by varying densities and distributions of melanocytes with arborizing dendrites, which were present in all BCCs. Melanophages within the stroma and basaloid cell melanization also contributed to pigmentation. No behavioral or biologic differences in pBCC were documented compared with clinically nonpigmented lesions.

The eDerm online curriculum: A randomized study of effective skin cancer teaching to medical students

With the incidence of skin cancers continuing to increase, traditional clerkships may not be sufficient to teach medical students important detection and management skills. We performed a randomized study to determine the efficacy of the online curriculum, eDerm. Students were randomized to complete eDerm before or after clerkship (arm 1 vs 2) and were tested at 3 time points, including at baseline. The crossover design examined eDerm and clerkship, and the sequential effect of both. In all, 252 participants completed all interventions and testing. Diagnosis and management scores significantly improved in both arms (P< .001; P< .001), reflecting increased scores after taking both eDerm and clerkship. eDerm after clerkship resulted in the highest improvement in diagnosis (P= .005), and eDerm improved the detection of melanoma significantly better than clerkship (malignant, P< .001; pigmented, P< .001). We did not perform delayed testing of medical students for learning retention. eDerm significantly improves the diagnosis and management of nonpigmented and pigmented skin lesions by medical students. It can be used as an alternative to a traditional 2-week clerkship if one is not available. Importantly, melanoma detection improved significantly more after eDerm than clerkship. When used as a supplement, eDerm administered after a clerkship will result in the highest level of overall learning.

Benefits of polarized versus nonpolarized dermoscopy

Dermoscopy is a widely diffuse tool that allows a better noninvasive diagnosis of pigmented and nonpigmented skin lesions, visualizing magnified images of subsurface structures. The light source can be nonpolarized or polarized, the latter being a more recent technique acquisition. Papers from the last decade focused on the appreciable differences between the two techniques. In general, by polarized dermoscopy the visualization of deeper and vascular structures is more attainable, but the main issue is the quality of the image, influencing both diagnostic accuracy and confidence level, regardless of the lighting technique. A terminology based on polarized dermoscopy is still missing, requiring further consensus-based studies.

Dermoscopy and Skin Cancer

When I started my residency training about 11 years ago, I was immediately fascinated by the new morphologic dimension of skin lesions that is offered by dermoscopy, and accordingly, I focused my research on dermoscopy. At that time and as a young researcher, a recurrent statement was that “dermoscopy is not for future research as everything has already been described.” Instead, looking back on the research activities in the field of dermoscopy during the last 10 years proves that I was living at the beginning of a new and evolving era of noninvasive, diagnostic imaging techniques. In fact, dermoscopy gained increasing interest over this past decade, which is also reflected by the increasing number of publications on dermoscopy per year. Using, for example, simply “dermoscopy” to search for publications in the ISI Web of Science reveals that the number of publications increased significantly from 17 publications in 2000 to 138 in 2010. As a result, dermoscopy can be considered today as an integrative part in the routine diagnosis and management of patients with skin lesions. The fact that even after 10 years of intense research we still discover new features that aid the diagnosis is well reflected by this special issue. In this issue, the dermoscopic features of pigmented intraepidermal carcinoma, CD8-positive solitary pagetoid reticulosis, black hairy tongue, cylindroma, eccrine porocarcinoma, and rippled sebaceoma are described. In addition, a study focusing on the influence of pregnancy on the recurrence of melanoma failed to show an increased risk for recurrence, while another study reports the data of a new transition metal complex for photosensitizing properties and dye-sensitized solar cell. To this end, I conclude that although dermoscopy in 2011 is no longer a new technique but has become a standard tool for the diagnosis and management of patients with pigmented and nonpigmented skin lesions, there is still need and place for further research in this field. Iris Zalaudek Giuseppe Argenziano Ashfaq A. Marghoob Giovanni Pellacani H. Peter Soyer

Reflectance Confocal Microscopy in the Daily Practice

Reflectance confocal microscopy (RCM) allows noninvasive imaging of the epidermis and superficial dermis. Like dermoscopy, RCM acquires images in the horizontal plane (en face), allowing assessment of tissue pathology underlying dermoscopic structures of interest at a cellular-level resolution. Thus, clinicians using dermoscopy may find RCM to be particularly useful. Our aim was to show the value of RCM for diagnosis and management decisions related to pigmented and nonpigmented skin neoplasms seen in daily practice. Six cases of clinically and dermoscopically equivocal skin lesions, for which RCM facilitated making the correct diagnosis, are presented. Final diagnoses were made based on histopathologic analysis. Three flat pigmented skin lesions with dermoscopic signs of regression showed distinct RCM features that allowed their correct classification as pigmented basal cell carcinoma, pigmented actinic keratosis, and melanoma on sun-damaged skin. A flat nonpigmented skin lesion on the face, which did not show distinct clinical or dermoscopic features, was correctly diagnosed as basal cell carcinoma based on RCM findings. In addition, the response of a pigmented actinic keratosis and a melanoma in situ on sun-damaged skin to noninvasive topical treatment was monitored using RCM. RCM is a promising and practical imaging tool for the diagnosis and follow-up of pigmented and nonpigmented skin lesions.

Impression cytology features of conjunctival nevi reported as more noticeable

To report the impression cytology features of conjunctival nevi reported as more noticeable. 35 patients who reported that a conjunctival lesion had become more noticeable after color or size change were enrolled. On slit-lamp examination, a clinical diagnosis of nevus was made and lesions underwent impression cytology using acetate cellulose strips and a combined staining with PAS, H&E and Papanicolaou. At patient's or parents' request, excision of the lesion was performed and the tissue was submitted to histopathological study. Impression cytology examination revealed nests or cluster of nevus cells within the epithelium layer containing or not mucous-secreting goblet cells in 32 cases (91.4%). Ten patients (28.5%) had the tumor removed and histopathological diagnosis was compound nevus in 8 eyes (1 from caruncle, 1 from plica semilunaris and 6 from bulbar conjunctiva) and subepithelial nevus from bulbar conjunctiva (2 eyes). Optical microscopy analysis of the impression cytology specimens confirmed the clinical diagnosis by demonstrating typical histopathological features of the superficial layers from conjunctival nevi in 91.4% of the cases. For amelanotic nevi IC can also allow a differential diagnosis from other nonpigmented lesions. The technique does not replace histopathological examination, but additionally, may assist in evaluating nevus cells in children and adults.

Factors Associated With the Number of Lesions Excised for Each Skin Cancer

To assess physician, patient, and skin lesion characteristics that affect the number of benign skin lesions excised by primary care physicians for each skin cancer. Prospective study collecting clinical, patient, and histopathologic details of excisions or biopsies of skin lesions by random samples of primary care physicians. Southeast Queensland involving traditional family medicine physicians (n = 104; response rate, 53.9%) and family medicine physicians working in 27 primary care skin cancer clinics (n = 50; response rate, 75.0%). Of 28 755 skin examinations recorded during the study, 11 403 skin lesions were excised or biopsied; 97.5% of the excised lesions had clinical and histologic diagnoses recorded. Number of lesions needed to excise or biopsy (NNE) for 1 melanoma (pigmented lesions only) and NNE for 1 nonmelanoma skin cancer (nonpigmented lesions only). The NNE for nonpigmented lesions (n = 8139) was 1.5 (95% confidence interval, 1.4-1.6) and for pigmented lesions (n = 2977) was 19.6 (16.2-22.9). The NNE estimates were up to 8 times lower if the physician thought the lesion was likely to be malignant and up to 2.5 times higher if there was strong patient pressure to excise. The NNE estimates varied by other physician-, patient-, and lesion-related variables. Clinical impressions of excised skin lesions were strongly associated with NNE estimates. By focusing on pigmented skin lesions and by addressing the physician- and patient-specific factors identified, the effectiveness of future training for primary care physicians in the clinical management of skin cancer could be improved.

Dermoscopic patterns of superficial basal cell carcinoma

Superficial basal cell carcinoma (BCC) presents as a scaly, pink to red-brown patch and is predominantly located on the trunk. Clinical diagnosis may not be always easy and implicates a variety of differential diagnoses; in this situation dermoscopy has been reported improving the diagnostic accuracy. This study investigated dermoscopic patterns of superficial BCC focalizing the most specific and frequent structures in order to improve the diagnostic accuracy. Study population referred to skin lesion clinic. Dermoscopic patterns of 42 superficial BCCs were analyzed and photographed. These cases represented the 8% of all BCCs excised in our Department between 2005 and 2006. Dermoscopic structures observed in the 42 superficial BCCs consisted of shiny white to red areas (100%), "erosions" (78.6%), short fine telangiectasias (SFTs) (66.6%), leaf-like areas (16.6%), arborizing telangiectasias (14.3%), blue-gray globules (14.3%) and large blue-gray ovoid nests (4.7%). Our study identifies the presence of shiny white to red areas, SFTs and "erosions" as main dermoscopic criteria of superficial BCC. Other dermoscopic features, such as leaf-like areas, arborizing telangiectasias, blue-gray globules and large blue-gray ovoid nests, are not strongly associated with the diagnosis of superficial BCC but they are useful in the differential diagnosis from other pigmented and nonpigmented skin lesions.

Digital Image Analysis for Diagnosis of Skin Tumors

Between 1987 and 2007, different groups developed digital image analysis systems for the diagnosis of benign and malignant skin tumors. As the result of significant differences in the technical devices, the number, the nature and benign/malignant ratio of included skin tumors, different variables and statistical methods any comparison of these different systems and their results is difficult. For the use and comparison of the diagnostic performance of different digital image analysis systems in the future, some principle basic conditions are required: All used systems should have a standardized recording system and calibration. First, melanocytic and nonmelanocytic lesions should be included for the development of the diagnostic algorithms. Critical analyses of the results should answer the question if in future only melanocytic lesions should be analyzed or all pigmented and nonpigmented lesions. This will also lead to the answer if only dermatologists or all specialities of medical doctors will use such a system. All artifacts (eg, hairs, air bubbles) should be removed. The number of variables should be chosen according to the number of included melanomas. A high number of benign skin lesions should be included. Of all lesions only 10% or better less should be invasive melanomas. Each system should be developed by a training-set and controlled by an independent test-set. Each system should be controlled by the user with the final decision and responsibility and tested by independent users without any conflict of financial interest.

A 17-month Infant with a Calf Lesion and Generalized Hypotonia

&lt;P&gt;A 17-month-old girl presented with a right calf lesion that had grown throughout 4 months and motor delay that had been present for 2 months. One week before admission, she also had anorexia and was irritable, but she had no fever. On admission, she had a temperature elevation to 100.7° F, and then she remained afebrile. She was well-nourished and not acutely ill but had generalized hypotonia and ataxia. There was a circular, indurated, dark red, 2.5-cm lesion on her right calf (see Figure 1) and two smaller subcutaneous, non-pigmented lesions on her left calf. The remainder of the physical examination was normal, including no hepatomegaly, splenomegaly, lymphadenopathy, or other focal neurologic findings. An ophthalmologist found no lesions in the optic fundi.&lt;/P&gt;&lt;H4&gt;ABOUT THE AUTHORS&lt;/H4&gt; &lt;P&gt;Helkha Peredo-Pinto, MD; and Norman M. Jacobs, MD, are with the Pediatrics Department, John Stroger Jr. Hospital of Cook County, Chicago, Illinois.&lt;/P&gt; &lt;P&gt;Address correspondence to: Helkha Peredo-Pinto, MD, Pediatrics Department, John Stroger Jr. Hospital of Cook County, 1901 W. Harrison St., 4th Floor, Suite #4806, Chicago, Illinois 60612; fax 312-864-9717; or e-mail: &lt;a href="mailto:helkha@hotmail.com"&gt;helkha@hotmail.com&lt;/a&gt;.&lt;/P&gt; &lt;P&gt;Dr. Peredo-Pinto and Dr. Jacobs have disclosed no relevant financial information.&lt;/P&gt; &lt;H4&gt;EDUCATIONAL OBJECTIVES&lt;/H4&gt; &lt;OL&gt;&lt;LI&gt;Review the pathogenesis of CNS tuberculoma and similarities with tuberculous meningitis.&lt;/LI&gt;&lt;LI&gt;Discuss the appropriate diagnostic evaluation of a patient with suspected CNS tuberculosis.&lt;/LI&gt;&lt;LI&gt;Determine the most effective therapy for a patient with extrapulmonary tuberculosis.&lt;/LI&gt;&lt;/OL&gt;

Digital Polarized Light Dermoscopy of Clinically Nonpigmented Dermal Nevi

BACKGROUND Hand-held dermoscopy improves the malignant/benign excision ratio for melanocytic lesions. Much has been described about its use in pigmented lesions; however, the use of dermoscopy in clinically nonpigmented lesions is less well studied. Existing studies have used a combination of traditional immersion dermoscopy and polarized light dermoscopy. This is the first study, to our knowledge, to strictly use digital polarized light dermoscopy for the evaluation of clinically nonpigmented, biopsy-proven dermal nevi. OBJECTIVE The goal of this study was to describe the dermoscopic features of clinically nonpigmented, biopsy-proven dermal nevi using digital polarized light images. METHODS AND MATERIALS The dermoscopic features of 32 histopathologically confirmed, clinically nonpigmented, dermal nevi were evaluated. Images were obtained with a digital camera equipped with an epiluminescence microscopy attachment (polarized light); no liquid interface was used. RESULTS The most frequent dermoscopic feature of 32 clinically nonpigmented, biopsy-proven dermal nevi was brown pigment (78%) followed by white areas (53%), comma-shaped vessels (50%), hair (47%), hairpin vessels (22%), comedolike openings (22%), and dotted vessels, respectively (19%). CONCLUSIONS The most common dermoscopic features (using polarized light) of clinically nonpigmented, biopsy-proven dermal nevi are brown pigment, white areas, comma-shaped vessels, and hair.

Digital Polarized Light Dermoscopy of Clinically Nonpigmented Dermal Nevi

Hand-held dermoscopy improves the malignant/benign excision ratio for melanocytic lesions. Much has been described about its use in pigmented lesions; however, the use of dermoscopy in clinically nonpigmented lesions is less well studied. Existing studies have used a combination of traditional immersion dermoscopy and polarized light dermoscopy. This is the first study, to our knowledge, to strictly use digital polarized light dermoscopy for the evaluation of clinically nonpigmented, biopsy-proven dermal nevi. The goal of this study was to describe the dermoscopic features of clinically nonpigmented, biopsy-proven dermal nevi using digital polarized light images. The dermoscopic features of 32 histopathologically confirmed, clinically nonpigmented, dermal nevi were evaluated. Images were obtained with a digital camera equipped with an epiluminescence microscopy attachment (polarized light); no liquid interface was used. RESULTS The most frequent dermoscopic feature of 32 clinically nonpigmented, biopsy-proven dermal nevi was brown pigment (78%) followed by white areas (53%), comma-shaped vessels (50%), hair (47%), hairpin vessels (22%), comedolike openings (22%), and dotted vessels, respectively (19%). The most common dermoscopic features (using polarized light) of clinically nonpigmented, biopsy-proven dermal nevi are brown pigment, white areas, comma-shaped vessels, and hair.

Dermoscopy of facial nonpigmented actinic keratosis

The accuracy of clinical diagnosis of nonpigmented, facial actinic keratosis (AK) is often suboptimal, even for experienced clinicians. To investigate the dermoscopic features of nonpigmented AK located on the head/neck that may assist the clinical diagnosis. Forty-one nonpigmented AKs on facial sites were examined by dermoscopy for any consistent underlying features. Lesions were gathered from skin cancer centres in Australia, Austria, Italy and the U.S.A. All cases were diagnosed histopathologically. Four essential dermoscopic features were observed in facial AK: (i) erythema, revealing a marked pink-to-red 'pseudonetwork' surrounding the hair follicles (95%); (ii) white-to-yellow surface scale (85%); (iii) fine, linear-wavy vessels surrounding the hair follicles (81%); and (vi) hair follicle openings filled with yellowish keratotic plugs (66%) and/or surrounded by a white halo (100%). These features combined, in 95% of cases, to produce a peculiar 'strawberry' appearance. A dermoscopic model of 'strawberry' pattern is presented, which may prove helpful in the in vivo diagnosis of nonpigmented, facial AK. A limitation of this study is the lack of testing of the specificity of the described dermoscopic criteria in differentiating nonpigmented AKs from other nonpigmented skin lesions at this site.

Detection of peritoneal endometriotic lesions by autofluorescence laparoscopy

This study was undertaken to evaluate the feasibility of autofluorescence laparoscopy in the diagnosis of endometriotic lesions. Prospective analysis of 83 consecutive patients undergoing laparoscopy for suspected endometriosis under white light illumination and autofluorescence diagnosis. The study measured total number of endometriotic lesions diagnosed under white light illumination and with autofluorescence diagnosis. The biopsy-based sensitivity of white light diagnosis alone and white light illumination and autofluorescence for detecting nonpigmented peritoneal endometriotic lesions was 65% compared with 92% (1.42-fold increase). The corresponding specificity was 68% as opposed to 84%. Occult areas of endometriosis were discovered using autofluorescence diagnosis. Statistical analysis was performed with chi2 test and McNemar test. Combination of white light illumination and autofluorescence is significantly superior to white light illumination alone in detecting nonpigmented endometriotic lesions. Autofluorescence diagnosis of nonpigmented endometriotic lesions may become an alternative to fluorescence diagnosis after application of 5-aminolevulinic acid, especially because of no side effects.