Pigmented Skin Lesion Biopsies After Computer-Aided Multispectral Digital Skin Lesion Analysis

BACKGROUND

The incidence of melanoma has been rising over the past century. With 37% of patients presenting to their primary care physician with at least 1 skin problem, primary care physicians and other nondermatologist practitioners have substantial opportunity to make an impact at the forefront of the disease process. New diagnostic aids have been developed to augment physician analysis of suspicious pigmented skin lesions (PSLs).

OBJECTIVE

To determine the effects of computer-aided multispectral digital skin lesion analysis (MSDSLA) on dermatologists' and nondermatologist clinicians' decisions to biopsy suspicious PSLs after clinical and dermatoscopic evaluation.

METHODS

Participants were shown 6 images of PSLs. For each PSL, participants were asked 3 times if they would biopsy the lesion: first after reviewing a clinical image of the PSL, again after reviewing a high-resolution dermatoscopic image, and again after reviewing MSDSLA probability findings. An answer was right if a melanoma or high-risk lesion was selected for biopsy or a low-risk lesion was not selected for biopsy. An answer was wrong if a melanoma or high-risk lesion was not selected for biopsy or a low-risk lesion was selected for biopsy. Clinicians' decisions to biopsy were evaluated using χ² analysis for proportions.

RESULTS

Data were analyzed from a total of 212 participants, 177 of whom were dermatologists. Overall, sensitivity of clinical image review was 63%; dermatoscopic image review, 5%; and MSDSLA, 83%. Specificity of clinical image review was 59%; dermatoscopic image review, 40%; and MSDSLA, 76%. Biopsy decision accuracy was 61% after review of clinical images, 52% after review of dermatoscopic images, and 80% after review of MSDSLA findings. The number of lesions participants indicated that they would biopsy increased significantly, from 52% after reviewing clinical images to 63% after reviewing dermatoscopic images (P<.001). However, the overall number of specimens that participants indicated they would biopsy did not change significantly after they reviewed MSDSLA findings (53%).

CONCLUSION

Sensitivity, specificity, and biopsy decision accuracy increased after clinicians reviewed MSDSLA findings. The use of objective, computer-based diagnostic aids such as MSDSLA during clinical evaluations of ambiguous PSLs could aid clinicians' decisions to biopsy such lesions.

Terra firma-forme dermatosis: Case Series and dermoscopic features

Terra firma-forme dermatosis (TFFD) is characterized by dirt-like skin lesions that disappear after rubbing with alcohol. We describe the dermoscopic features of TFFD before and after alcohol swabbing in six patients. All patients showed similar dermoscopic appearance with large polygonal plate-like brown scales arranged together giving a mosaic pattern. These features disappear completely after isopropyl alcohol swabbing of the lesions. In conclusion dermoscopy can assist in the evaluation of terra firma-forme dermatosis and the dermoscopic evaluation of other dirty dermatoses is recommended in the future to compare findings with TFFD.

The practical usefulness of dermoscopy in general dermatology

Beside to traditional use, dermoscopy is more and more used in the assessment of other "general" dermatologic conditions, namely scalp and hair disorders (trichoscopy), nails abnormalities (onychoscopy), skin infections and infestations (entomodermoscopy), and cutaneous inflammatory diseases (inflammoscopy). Among the list of new applications of dermoscopy, the study of inflammatory dermatoses is probably the most promising topic in terms of development and usefulness, considering the large number of such disorders and the frequent problems in their differential diagnosis which the dermatologist encounters in own daily clinical practice. In this paper, we report selected relatively common clinical differential diagnosis issues concerning inflammatory dermatoses (and some clinically related noninflammatory conditions), analysing them by a dermoscopic point of view in order to assist their noninvasive resolution according to the available literature data and our personal experience, including papulosquamous dermatoses (guttate psoriasis, pityriasis lichenoides chronica, pityriasis rosea, lichen planus, lymphomatoid papulosis, classic pityriasis rubra pilaris, papulosquamous sarcoidosis, disseminated forms of porokeratosis and papulosquamous chronic GVHD), dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides, subacute cutaneous lupus erythematosus), palmar psoriasis vs. chronic hand eczema, scalp psoriasis vs. seborrheic dermatitis, erythematous-desquamative disorders typically involving the elbows (psoriasis vulgaris, circumscribed juvenile pityriasis rubra pilaris, dermatomyositis/Gottron's sign), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), common facial inflammatory skin diseases (rosacea, seborrheic dermatitis and demodicidosis), lichen sclerosus vs. morphea, urticaria vs. urticarial vasculitis and common inflammatory cicatricial alopecia (discoid lupus erythematosus, lichen planopilaris and folliculitis decalvans).

Update on the use of confocal microscopy in melanoma and non-melanoma skin cancer

Reflectance confocal microscopy (RCM) is a new technique enabling the visualization of the skin at a quasi-histological resolution, allowing the identification of clues for the diagnosis of skin diseases. The aim of this analysis was to provide new insights into the role of RCM in the diagnosis of skin cancers. Data comes from the most recent literature, taking into account previous essential reported information in this field. The study eligibility criteria were: studies providing update information, focusing on RCM findings in melanoma and non-melanoma skin cancers (NMSC), without restrictions for age, sex, ethnicity. Duplicated studies and single case report were excluded from this study. A search concerning the role of RCM in melanoma and NMSC was performed on the Medline. RCM clues were analyzed for different skin cancers, in particular melanoma and NMSC, in association with clinical, dermoscopic and histopathologic findings. Diagnostic accuracy, sensibility and specificity of the technique were reviewed. Furthermore, some new findings have been described and recent applications have been discussed. The selection of articles was limited in order to provide an up-to-date revision. In conclusion, several RCM features were implemented for the diagnosis of melanoma and NMSC, leading to a confocal-based classification in most cases.

High frequency ultrasonography: a complementary diagnostic method in evaluation of primary cutaneous melanoma

AIM

The aim of our study was to assess the usefulness of high frequency ultrasonography in the diagnosis of melanoma.

METHODS

We examined 84 patients with suspicious melanocytic skin lesions, including 19 cases of melanoma. In vivo high-resolution ultrasonography (30 MHz) was performed prior to excision.

RESULTS

In ultrasound scans early melanomas presented as flat oval or fusiform shaped structures and were clearly demarcated, while advanced melanomas were characterized by a roundish shape with less distinct borders. The ultrasonographic thickness of in situ melanomas ranged from 0.02 to 0.85 mm. In the case of invasive tumors, the mean thickness evaluated by high frequency ultrasonography was 10.7% higher compared to the Breslow Score (1.44±0.8 mm and 1.3±0.88 mm, respectively). In all melanomas of Breslow Score of 1 mm or more ultrasound also indicated a Breslow Score of 1 mm or more.

CONCLUSION

High frequency ultrasound examination has limited value in differential diagnosis of melanoma, but it gives a clear picture of the size and depth of the tumor. The method should be used as a complementary method (after dermoscopy and, where applicable, reflectance confocal microscopy) in preoperative evaluation of the tumor. In some cases of locally advanced melanoma, ultrasound examination may allow to reduce the number of surgical procedures and favor the decision of a one-time surgical treatment (removal of primary tumor and sentinel lymph node biopsy at the same time).

Dermoscopy of melanoma and non-melanoma skin cancer

Skin cancer is a major health problem because of its high incidence in white populations, as well as its related potential morbidity and mortality. Dermoscopy is a noninvasive tool that allows the identification of specific morphological features in different skin tumors, improving significantly the early diagnosis of melanoma and non-melanoma skin cancer (NMSC). This tool has also gained increased interest in the management of NMSC therapy and in the post-treatment follow-up. In this article, we provide a review of the dermoscopic patterns and criteria for the diagnosis of melanoma and NMSC described until now in the literature.

Dermatoscopy in inflammatory and infectious skin disorders

Dermatoscopy is a non-invasive technique that allows a rapid and magnified in vivo observation of the skin surface. By definition, it is performed with handheld devices (dermatoscopes) allowing X10 magnification. More expensive, computer-assisted digital systems (videodermatoscopes) may be equipped with lenses that ensure magnifications up to X1000; in this case the term videodermatoscopy is generally used. Dermatoscopy is mainly utilized for the evaluation of pigmented skin lesions, and has increasing applications in dermatology. In this paper the use of dermatoscopy in a variety of inflammatory (psoriasis, lichen planus, pityriasis lichenoides, rosacea, lichen sclerosus, Darier's disease, pigmented purpuric dermatoses) and infectious (human papillomaviruses infections, molluscum contagiosum, tinea capitis, tinea nigra, scabies, head and pubic lice, tungiasis, cutaneous leishmaniasis and cutaneous larva migrans) cutaneous disorders will be analyzed. In these conditions, dermatoscopy may assist the clinical diagnosis, reducing the need of semi-invasive or invasive procedures such as skin scrapings and/or biopsy. Depending on the disease, the choice to use low or high magnifications may be crucial. Dermatoscopy may also be useful for prognostic evaluation and monitoring of response to treatment, representing an important and relatively simple aid in daily clinical practice.

The Skin Cancer Objective Structured Clinical Examination (SCOSCE): A multi-institutional collaboration to develop and validate a clinical skills assessment for melanoma

BACKGROUND

Assessing medical students on core skills related to melanoma detection is challenging in the absence of a well-developed instrument.

OBJECTIVE

We sought to develop an objective structured clinical examination for the detection and evaluation of melanoma among medical students.

METHODS

This was a prospective cohort analysis of student and objective rater agreement on performance of clinical skills and assessment of differences in performance across 3 schools.

RESULTS

Kappa coefficients indicated excellent agreement for 3 of 5 core skills including commenting on the presence of the moulage (k = 0.87, 95% confidence interval 0.77-0.96), obtaining a history for the moulage (k = 0.84, 95% confidence interval 0.74-0.94), and making a clinical impression (k = 0.80, 95% confidence interval 0.68-0.92). There were no differences in performance across schools with respect to 3 of 5 core skills: commenting on the presence of the moulage (P = .15), initiating a history (P = .53), and managing the suspicious lesion (P value range .07-.17). Overall, 54.2% and 44.7% of students commented on the presence of the moulage and achieved maximum performance of core skills, respectively, with no difference in performance across schools.

LIMITATIONS

Limitations include overall sample size of students and schools.

CONCLUSION

The Skin Cancer Objective Structured Clinical Examination represents a potentially important instrument to measure students' performance on the optimal step-by-step evaluation of a melanoma.

The reflectance confocal microscopy in diagnosis of recurrent basal cell carcinoma

BACKGROUND

Reflectance confocal microscopy (RCM) is very valuable, non-invasive diagnostic tool in the diagnosis of basal cell carcinoma (BCC). Objective: We aimed to demonstrate the positive predictive value (PPV), negative predictive value, sensitivity and specificity of RCM and dermoscopic features in recurrent BCC.

METHODS

The 152 entire lesion sites in 128 patients with BCC were evaluated by clinical examination, dermoscopy and RCM imaging techniques. Biopsy was performed from 46 lesions if there was at least one of the clinical findings or at least one of the diagnostic criteria of BCC with dermoscopy or RCM examination. Histopathological examination was considered as a gold standard for the diagnosis of recurrence BCC.

RESULTS

Recurrence was observed in 29 cases (63%). In the dermoscopic examination, arborizing telangiectasia and blue-grey globules were found to be statistically significantly correlated with BCC recurrence (p<0.05). The specificity and PPV of nucleated corneocytes in the stratum corneum and polarisation of elongated nuclei in the epidermis was 100%. PPV of streaming of aggregated tumour cells and variable refractile stroma was 92% with RCM examination.

CONCLUSION

RCM is a diagnostic tool with a high PPV, sensitivity and specificity for the diagnosis of recurrence of BCC lesions.

[GAZING INTO A CRYSTAL BALL AND DETECTING SUBJECTS AT RISK FOR DEVELOPING CUTANEOUS MELANOMA]

Cutaneous melanoma is the deadliest skin cancer showing an increasingly growing incidence in white populations of Europe and United States. Intensive research in recent years has begun to unlock its molecular pathogenesis. Screening the neoplasm at an early stage remains primordial. Hence, targeting populations at risk is likely efficient. In such an attempt, the regular clinical examination benefits from a series of non invasive procedures such as skin surface biopsies, in vivo confocal microscopy, dermoscopy and specular fluorescent light reflectance.

Dermoscopy and Early Melanoma

The lack of effective therapies for patients with advanced melanoma establishes an early recognition as the aim of clinical and dermoscopic examination, which is the most important factor for improving patient survival and decreases the treatment and management costs. Melanoma in situ is the earliest stage of melanoma. The features of early melanomas, especially in those lesions smaller than 3mm, can be very subtle clinically, dermoscopically and pathohistologically, and it is often impossible to discriminate between a melanoma and nevus. Clinically, de novo melanomas are small brown to black macula with an irregular outline. In melanomas developing in a nevus, there is an asymmetry of the lesion with marked change in color and/or shape of the pre-existing nevus. Dermoscopically, early stages of melanoma show the same global features as thicker melanomas, but in a more subtle way. Asymmetry is the most important parameter; multiple colors are rare. Significant local melanoma-specific criteria, especially when present at the periphery, are irregular pigment network, irregular streaks, and irregular dots/globules, while blue-white structures are rarely found.

PH² - a dermoscopic image database for research and benchmarking

The increasing incidence of melanoma has recently promoted the development of computer-aided diagnosis systems for the classification of dermoscopic images. Unfortunately, the performance of such systems cannot be compared since they are evaluated in different sets of images by their authors and there are no public databases available to perform a fair evaluation of multiple systems. In this paper, a dermoscopic image database, called PH², is presented. The PH² database includes the manual segmentation, the clinical diagnosis, and the identification of several dermoscopic structures, performed by expert dermatologists, in a set of 200 dermoscopic images. The PH² database will be made freely available for research and benchmarking purposes.

Update on non-invasive imaging techniques in early diagnosis of non-melanoma skin cancer

Non-melanoma skin cancer (NMSC) is the most common malignancy in fair skinned populations. Dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) are non-invasive imaging techniques that play an important role in diagnosis of skin tumors. The aim of this study was to provide new insights into the role of non-invasive tecniques in the diagnosis of non-melanoma skin cancers, concentrating especially on dermoscopy, RCM and OCT. The analysis of the studies obtained from the most recent literature, taking into account previous essential reported information in this field. A search concerning the role of dermoscopy, RCM and OCT in the diagnosis of NMSC was performed on PubMed.

EXCLUSION CRITERIA

duplicated studies, single case report, and papers with language other than English New and old literature about early diagnosis of NMSC through non-invasive imaging techniques were analyzed. The role and the diagnostic accuracy of dermoscopy, RCM and OCT for the diagnosis of NMSC were reported according to the data given by literature. The development of non-invasive diagnostic devices (especially dermoscopy, RCM and OCT) allows tissue imaging in-vivo contributing to a more accurate diagnosis of skin cancer, sparing time for the patient and costs for the public health system.

Surgical treatment of basal cell carcinoma and squamous cell carcinoma

Non melanoma skin cancers (NMSC) are the most common human neoplasms, encompassing basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), but also cutaneous lymphomas, adnexal tumors, merckel cell carcinoma and other rare tumors. The incidence of BCC and SCC varies significantly among different populations, and the overall incidence of both tumors has increased over the last decades. Although generally associated with a favorable prognosis, recent evidence suggests that the mortality rates of SCC might have been underestimated up-to-date.1 According to Medicare data, NMSC is the fifth most expensive cancer for health care systems. This increased economic burden is not associated with the cost of treating an individual patient, but with the large number of affected patients and the recurrence rates.2 Therefore, the adequate management of the primary tumor with a complete excision becomes a priority not only for the patient but also for the public health systems. Multiple treatment modalities are currently usedin clinicalpractice for the treatment of NMSC. While surgical excision (SE) remains the gold standard of care, non-surgical techniques have gained appreciation due to lower morbidity and better cosmetic results. The optimal management of treatment includes a complete tumor clearance, preservation of the normal tissue function, and the best possible cosmetic outcome.3 Surgery with a predefined excision margin is the treatment of choice for most NMSCs, with Mohs micrographic surgery being recommended for tumors considered to be at a higher recurrence risk or those developing on cosmetically sensitive areas.4, 5 Therefore, the surgical approach of a NMSC consists with three different and equally important steps. First the preoperative clinical assessment of the tumor margins, which can be facilitated by the use of dermoscopy. Second, the definition of the surgical margins depending on the tumor subtype and its biological behavior. Finally, the surgical procedure must be designed based on the anatomic site and the patient's charachteristics. This preoperative assessment requires specific skills and might be performed by a physician, the dermatosurgeon, two collaborating specialists, namely a dermatologist and a surgeon.

Automatic differentiation of melanoma from dysplastic nevi

Malignant melanoma causes the majority of deaths related to skin cancer. Nevertheless, it is the most treatable one, depending on its early diagnosis. The early prognosis is a challenging task for both clinicians and dermatologist, due to the characteristic similarities of melanoma with other skin lesions such as dysplastic nevi. In the past decades, several computerized lesion analysis algorithms have been proposed by the research community for detection of melanoma. These algorithms mostly focus on differentiating melanoma from benign lesions and few have considered the case of melanoma against dysplastic nevi. In this paper, we consider the most challenging task and propose an automatic framework for differentiation of melanoma from dysplastic nevi. The proposed framework also considers combination and comparison of several texture features beside the well used colour and shape features based on "ABCD" clinical rule in the literature. Focusing on dermoscopy images, we evaluate the performance of the framework using two feature extraction approaches, global and local (bag of words) and three classifiers such as support vector machine, gradient boosting and random forest. Our evaluation revealed the potential of texture features and random forest as an almost independent classifier. Using texture features and random forest for differentiation of melanoma and dysplastic nevi, the framework achieved the highest sensitivity of 98% and specificity of 70%.

[Penile dermatoses]

The diagnostics of penile skin alterations represent a urological and dermatological challenge. The spectrum of differential diagnoses ranges from benign skin alterations with no clinical significance, through infections, vesiculobullous diseases and neoplasms up to acute diseases necessitating emergency interventions. Evidence-based therapy concepts are not available for all these diseases and due to the rarity an interdisciplinary cooperation is expedient and promising.

Delineating margins of lentigo maligna using a hyperspectral imaging system

Lentigo maligna (LM) is an in situ form of melanoma which can progress into invasive lentigo maligna melanoma (LMM). Variations in the pigmentation and thus visibility of the tumour make assessment of lesion borders challenging. We tested hyperspectral imaging system (HIS) in in vivo preoperative delineation of LM and LMM margins. We compared lesion margins delineated by HIS with those estimated clinically, and confirmed histologically. A total of 14 LMs and 5 LMMs in 19 patients were included. HIS analysis matched the histo-pathological analysis in 18/19 (94.7%) cases while in 1/19 (5.3%) cases HIS showed lesion extension not confirmed by histopathology (false positives). Compared to clinical examination, HIS defined lesion borders more accurately in 10/19 (52.6%) of cases (wider, n = 7 or smaller, n = 3) while in 8/19 (42.1%) cases lesion borders were the same as delineated clinically as confirmed histologically. Thus, HIS is useful for the detection of subclinical LM/LMM borders.

Reflectance confocal microscopy: an overview of technology and advances in telepathology

The value of in vivo reflectance confocal microscopy (RCM) as a noninvasive adjunctive tool in dermatology has steadily advanced since its inception. With RCM, dermatologists can view horizontal sections of lesions in a resolution comparable to histology, observe dynamic processes in living skin, and monitor lesion evolution longitudinally. This article will compare RCM to dermoscopy and histology, review the general principles of the microscope, describe the findings seen on confocal images, and discuss the clinical applications of this noninvasive tool. Additionally, we describe a telepathology network dedicated to the transfer of confocal images to remote dermatopathologists for interpretation. Finally, we will discuss the adoption of RCM and the telepathology network in clinical practice.

Snapshot RGB mapping of skin melanin and hemoglobin

The concept of snapshot red-green-blue (RGB) multispectral imaging was applied for skin chromophore mapping. Three monochromatic spectral images have been extracted from a single RGB image dataset at simultaneous illumination of skin by 473-, 532-, and 659-nm laser lines. The spectral images were further transformed into distribution maps of skin melanin, oxyhemoglobin, and deoxyhemoglobin, related to pigmented and vascular skin malformations. The performance and clinical potential of the proposed technique are discussed

Measuring skin aging using optical coherence tomography in vivo: a validation study

Dermal and epidermal structures in human skin change during intrinsic and extrinsic aging. Epidermal thickness is one of the most often reported parameters for the assessment of skin aging in cross-sectional images captured by optical coherence tomography (OCT). We aimed to identify further parameters for the noninvasive measurement of skin aging of sun-exposed and sun-protected areas utilizing OCT. Based on a literature review, seven parameters were inductively developed. Three independent raters assessed these parameters using four-point scales on images of female subjects of two age groups. All items could be detected and quantified in our sample. Interrater agreement ranged between 25.0% and 83.3%. The item scores “stratum corneum reflectivity,” “upper dermal reflectivity,” and “dermoepidermal contrast” showed significant differences between age groups on the volar and dorsal forearm indicating that they were best able to measure changes during skin aging. “Surface unevenness” was associated with the skin roughness parameters, Rz and Rmax, on the inner upper arm and volar forearm supporting the criterion validity of this parameter on sun-protected skin areas. Based on the interrater agreement and the ability to differentiate between age groups, these four parameters are being considered as the best candidates for measuring skin aging in OCT images.

Hyperspectral imaging-based wound analysis using mixture-tuned matched filtering classification method

Hyperspectral imaging is a technology that is beginning to occupy an important place in medical research with good prospects in future clinical applications. We evaluated the role of hyperspectral imaging in association with a mixture-tuned matched filtering method in the characterization of open wounds. The methodology and the processing steps of the hyperspectral image that have been performed in order to obtain the most useful information about the wound are described in detail. Correlations between the hyperspectral image and clinical examination are described, leading to a pattern that permits relative evaluation of the square area of the wound and its different components in comparison with the surrounding normal skin. Our results showed that the described method can identify different types of tissues that are present in the wounded area and can objectively measure their respective abundance, which proves its value in wound characterization. In conclusion, the method that was described in this preliminary case presentation shows promising results, but needs further evaluation in order to become a reliable and useful tool.

Optimization of irradiance for photodynamic therapy of port-wine stain

Controllable and effective irradiation of lesions is among the key factors that affect the potency of photodynamic therapy (PDT). An optimization method for the irradiance distribution of treatment was proposed which can be used to improve the efficacy of PDT and allow more lesions to receive the desired irradiance level in a single therapy session. With the proposed digital illumination binocular treatment system, the preferred surface normal vectors, irradiation angles, as well as area and weight coefficients of lesions can be achieved and used as characteristic parameters to optimize the irradiation direction. Two port-wine stain phantom experiments were performed. The comparison of the illumination area between preoptimization and postoptimization showed that the proposed method can effectively guide the light source control, improve the distribution of light dose, and increase the effective treatment area.

[What's new in pediatric dermatology]

Progress in paediatric dermatology is achieved in both research and therapeutic fields. In infectiology, scabies and bed bugs are a scourge for dermatologists, with an important recent outbreak. This article describes the fundamental clinical signs to look for, when suspecting such diagnosis. Hair dermatoscopy seems to be also very precious as a new tool for the diagnosis of ringworm. Regarding eczemas, atopic dermatitis is supported by S. Aureus's skin colonization, the target of eradication of new products in ongoing studies. We will also explain the role of Hemangiol, recently marketed in Switzerland for the treatment of haemangiomas. Alternative beta blockers have also a large number of ongoing projects in the dermatological vascular diseases field. Other various news is to be discovered....