ted rosen, md baylor college of medicine houston, texas
TRANSCRIPT
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Dermoscopy
Enhanced Diagnostic Ability: Pigmented Lesions
Ted Rosen, MD
Baylor College of Medicine
Houston, Texas
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Faculty Disclosure Statement
• No conflicts relevant to this workshop!
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Sir William Osler
• There is no more difficult art to acquire
than the art of observation. Many look,
but few see.
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Risk of Invasive Melanoma
• 1930 1/1500
• 1950 1/600
• 1980 1/250
• 1985 1/150
• 1993 1/100
• 2000 1/74
• 2007 1/60
• 2010 1/56
• 2015 1/50 (projected)
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Dermoscopy
• Dermatoscopy
• Epiluminescence microscopy (ELM)
• Surface microscopy
• Skin surface microscopy
• Magnified diascopy
• Oil immersion diascopy
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Dermoscopy
• Render the superficial epidermal
component transparent
• View deeper epidermis and dermis
• Oil + Magnification
• Polarized light + Magnification
• Polarized light superior in
examination of pigmented lesions
Dermatol Surg 34:1389, 2008
• Almost ART! Semi-SCIENCE!
• Takes time and experience
• ADJUNCTIVE procedure, never
replaces clinical judgment
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Welch-Allyn Episcope
~$375-$500 Heine Deltascope
~$500
Oil-Based Dermoscopy
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Dermoscopy: No Oil
Polarized Light
Dermlite
DL100
3 GEN
10x
magnification
Polarized light
877-694-9777
Dermlite.com $375
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Rechargeable (Lithium Ion)
$995
Switchable LED
to polarizer
10x magnification
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Lumio
2x magnification
LED + Polarizer
Replaceable batteries
Good for general skin
exam or large areas
$495
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Automated Analysis
• Digital magnified image
to computer
• Lesion assessed by
pre-set criteria
• Lesion “scored”
• Cancer probability
• Images saved
• MelaFind® MoleMax®
• SIAscope®, SolarScan®
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Dermoscopy v. Computer
• Of note: computer assisted
dermoscopy may have HIGHER
false positive rate than hand held
procedure!
• Up to false positive 26%
Br J Dermatol 143:1016, 2003
• At best, it is equivalent to hand-held
units with experienced clinicians
Br J Dermatol 157:926, 2007 and 161:591, 2009
• There is still a role for the human
being in diagnosis!
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Dermoscopy v. Standard
Total Body Photography
• 1067 patients
• Underwent total body photography
• Followed by comparison of in vivo
skin to photographs versus
dermoscopy
• Photographic follow had fewer
biopsies & lower mole : melanoma
ratio among lesions biopsied
• Derm Surg 36:1087-98, 2010
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DO YOU NEED DERMOSCOPY FOR
EVERY PIGMENTED LESION?
• Of course not!
• Some lesions are
OBVIOUS
• Helps to raise or lower
index of suspicion with
equivocal lesions
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No Dermoscopy Needed!
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Pick the Melanoma
A
B
C
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Pick the Melanoma
A
B
C
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Dermoscopy: Utility I
• Does it REALLY help?
Increased diagnostic accuracy among
family physicians by 40%
Br J Derm 143:1016, 2000 J Clin Oncol 24:1877, 2006
• Are there FALSE POSITIVES?
Yes, but these are uncommon
2.5-8% false positives
JEADV 15:24, 2001
Melanoma Res 13:179, 2003
• Are there FALSE NEGATIVES?
Yes, but these are very rare
J Am Acad Dermatol 46:957, 2002
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Dermoscopy: Utility II
• When compared to naked eye
examination of pigmented lesions,
dermoscopy increases PROPER
diagnosis of melanoma by up to
15x baseline, more so with more
experience using technique
• Br J Dermatol 159:669, 2008
(Meta-analysis of all prior studies)
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Dermoscopy Texts
Buy one. Any one. Read it. Re-read it.
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Dermoscopy Texts
Buy one. Any one. Read it. Re-read it.
*
*
Menzies
Malvehy
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Dermoscopy
• GENERAL CHARACTERISTICS
• Homogeneous v. Heterogeneous
• Symmetrical v. Asymmetrical
• SPECIFIC FEATURES
• Consensus Conference 1990
identified 22 distinct features
• These have been condensed
into various checklists
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Dermoscopy
Heterogeneous Homogeneous
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Dermoscopy
Asymmetrical Symmetircal
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Dermoscopy
Asymmetrical Symmetircal
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Dermoscopy
• Regular pigment net
• Irregular pigment net
• Prominent pigment net
• Discrete pigment net
• Wide pigment net
• Narrow pigment net
• Broad pigment net
• Delicate pigment net
• Pseudopod
• Radial streaming
• White veil
• Black dots
• Brown globules
• White scar-like area
• Blue-grey area
• Hypopigmentation
• Reticular depigment
• Milia-like cyst
• Comedo-like opening
• Telangiectasia
• Red-blue areas
• Maple-leaf areas
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Dermoscopy: Algorithms
• ABCD rules
Stolz: Semin Cutan Med Surg 22:9, 2003
• Menzies scoring method
Menzies: Arch Dermatol 132:1178, 1996
• CASH Algorithm
Henning: J Am Acad Derm 56:45, 2007
• 7-point checklist system
Argenziano: Arch Dermatol 134:1563, 1998
All systems perform equally! Arch Derm 141:1008, 2005
The first three are cumbersome.
The 7-point checklist is predominant method.
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Dermoscopy: Algorithms
• ABCD rules 77.5%
• Menzies scoring method 84.6%
• CASH Algorithm 68.4%
• 7-point checklist system 89.4%
Relative sensitivity in the hands of a NON-expert
Arch Dermatol 141:1008, 2005
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7 Point Checklist
• MAJOR CRITERIA (2 points)
Atypical pigment network
Blue-white veil
Atypical vascular pattern
• MINOR CRITERIA (1 point)
Irregular streaks (streaming, pseudopods)
Irregular pigmentation
Irregular dots or globules
Regression structures
• Total score > 3 highly suspect MM
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7 Point Checklist
• MAJOR CRITERIA (2 points)
Atypical pigment network
Blue-white veil
Atypical vascular pattern
• MINOR CRITERIA (1 point)
Irregular streaks (streaming, pseudopods)
Irregular pigmentation
Irregular dots or globules
Regression structures
• Total score > 3 highly suspect MM
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Pigment Network
• Fundamental
structure
• Grid of connected
pigmented lines
• Due to: pigmented
rete ridges in the
lower epidermis
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Pigment Network
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Irregular Pigment Network
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Irregular Pigment Network
Not symmetric and Not homogeneous
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Irregular Pigment Network
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Irregular (Atypical) Network
Specificity 80-86%
Sensitivity 30-35%
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Dots and Globules
• Fundamental
structure
• Large to small
spot-like pigment
• Due to: nests of
pigment-laden cells
at DEJ or in upper
dermis
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Dots and Globules
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Dots and Globules
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Irregular Dots and Globules
Specificity 80%
Sensitivity 50%
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Irregular Pigmentation
• Irregular shape
• Irregular distribution
• Multiple colors
• Due to: very random
pigment throughout
epidermis and dermis
Specificity 46%
Sensitivity approaches 100%
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Irregular Pigmentation
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Irregular Streaks
• At lesional edge
• Well defined structures
• Should NOT be there
• Radial streaming
Finger-like extensions
• Pseudopods
Bulbous extensions
• Due to peripheral
expansion along DEJ
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Radial Streaming
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Radial Streaming
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Radial Streaming
96% specificity
18% sensitivity
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Pseudopods (types)
A
B
C
D
E
F-I
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Pseudopods
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Blue-White Veil
• Whitish-colored film overlying
amorphous blue to blue-grey
• White: thickened epidermis
• Blue: heavily pigmented dermal
melanocytes
• Should not be there in normal
nevocellular or other growths
• Relatively specific for melanoma
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Blue-White Veil
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Blue-White Veil
Specificity 97%
Sensitivity 51%
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Blue-White Veil
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Blue-White Veil
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Regression Structures
• Bone white areas
• Represent tumor “regression”
• ? Response to immune attack
• Due to: loss of melanin
and/or fibrosis
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Regression Structures
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Regression Structures
Specificity 92-93%
Sensitivity 36-46%
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Atypical Vascular Pattern
• Least common
• Hardest to show
• Linear or dotted
blood vessels
• Due to: dermal
neovascularization
• That is: tumor
induces its own
blood supply Specificity 60-70%
Sensitivity 8%
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression ? 1
TOTAL SCORE = 2
BIOPSY = DYSPLASTIC NEVUS
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
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Irregular Pigment
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
TOTAL SCORE = 5
BOPSY: SSMM 1.1mm
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
TOTAL SCORE = 0
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
TOTAL SCORE = 0
BIOPSY = JUNCT’L NEVUS
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
TOTAL SCORE = 5
BIOPSY = SSMM 0.33mm
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• Irregular pigment 1
• Irregular streak 1
• Irregular dots 1
• Regression 1
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Dermoscopy in Action
• Blue-White Veil 2
• Atypical Vascular 2
• Atypical Network 2
• ?Irregular pigment1
• Irregular streak 1
• Irregular dots 1
• Regression 1
TOTAL SCORE = 0-1
BIOPSY = JUNCT’L NEVUS
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Seborrheic keratosis
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Seborrheic Keratosis
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Comedone-like Plugs
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Milia-like Cysts
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Seborrheic Keratoses & MM
SK MM
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Search Carefully!
Where is the dangerous lesion?
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What is this lesion?
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Dermoscopy
NOTE: Multiple red-blue globules
This is pathognomonic for hemangioma
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What is this lesion?
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Dermoscopy
Senile angioma
(Cherry angioma)
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Basal Cell Carcinoma
• Arborizing vessels
• Crusts
• If pigment present, delicate leaf-
like structures or individual small
globules
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Dermoscopy
• Easy to do and non-invasive
• Augments direct observation
• Careful scoring leads to
reproducible results
• Helps distinguish lesions
that must be removed or
biopsied from those that
can remain or be observed
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Other New Techniques
• Multispectral imaging
• Confocal scanning laser
microscopy
• Ultrasound
• Optical coherence tomography
• Magnetic resonance imaging
J Am Acad Derm 49:777-97, 2003
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Johann Goethe
• What is the most difficult thing of
all? That which seems the easiest:
to see with your eyes that which
lies right before your eyes.