Key factors in successfully integrating dermoscopy into your clinical practice

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Aubrey McGee
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1 Key factors in successfully integrating dermoscopy into your clinical practice S051 Dilemmas and challenges in skin cancer therapies and management Monday, March 4 th 2019 (9AM-12PM) Room 209A 10:56-11:09AM Ashfaq A. Marghoob Attending Physician

2 Disclosures Books: royalties Lecturing & Organizing meetings: Honorarium (3GEN) Advised & tested equipment: 3GEN, Canfield, Heine

3 Key to success 1. Proximity 2. Knowledge acquisition (the basics) 3. Practice, Predict, Compare 4. Eureka

4 1. Proximity Greatest barrier to learning dermoscopy is infrequent use due to the dermatoscope not being within easy reach In a closet or drawer In your office Shared between clinicians

Key to Success Own your own dermatoscope

5 Key to Success Own your own dermatoscope Keep it with you at all times during the clinical encounter I have it in my hand and use it to: Illuminate the skin (especially areas in shadows) & to side-light lesions Magnify lesions Evaluate dermoscopic structures

7 2. Knowledge acquisition (the basics) Structures (terminology) with their histopathology correlations

Nails Face Designed by Ralph P. Braun & Ashfaq A. Marghoob Palms and soles Designed by Ralph P. Braun & Ashfaq A. Marghoob. dermoscopedia.org Designed by Ralph P.

Nevu (also, see card s 2) Network Patchy network Peripheral Peripheral network & network & central central hyperpigmentatio hypopigmentatio n n Peripheral network

context (melanoma should be in the differential) Specific dermoscopic structures 2. DF/IDN 3. BCC 4. SCC dermoscopedia.

globules blotch Arborizing / Spoke wheel like Leaf like Blue gray ovoid Multiple blue branched Shiny white blotches & structures areas nests gray vessels strands

vessels with whitish halo Two component pattern Kissing nevus Structureless tan / pink pattern Nevi in skin type 1 Multi component pattern Symmetric Tiered

Usually display a multicomponent disorganized pattern with at least one melanoma specific structure depicted on (Card 3) 3.

On sun-damaged skin they often appear as large lentiginous lesions with the patterns shown below 5.

Hairpin vessels with whitish halo Melanoma on sun damaged skin 6.

arrangement Step 2: Look for melanoma patterns & structures (Card 2&3) Multi component patternasymmetric Structureless brown Structureless: Blue black nodule

locations Atypical network Angulated lines Negative network Atypical streaks Atypical dots and globules Regression structures Tan structureless areas Prominent

specific structures multiple small hyperpigmented areas Atypical blotches Raised blue white structureless area Blue white veil Granularity / peppering Regression

9 Nails Face Designed by Ralph P. Braun & Ashfaq A. Marghoob Palms and soles Designed by Ralph P. Braun & Ashfaq A. Marghoob. dermoscopedia.org Designed by Ralph P. Braun & Ashfaq A. Marghoob. 2 Step algorithm Step1 1. Nevu (also, see card s 2) Network Patchy network Peripheral Peripheral network & network & central central hyperpigmentatio hypopigmentatio n n Peripheral network & central globules Globular Globular Cobblestone Reticular Peripheral globules Homogenous blue Homogenous brown Special considerations Nevus patterns that require context (melanoma should be in the differential) Specific dermoscopic structures 2. DF/IDN 3. BCC 4. SCC dermoscopedia.org DF: network DF: network with ringlike globules, shiny white IDN: comma/curved vessels, with central brown halo, brown pigmentation, white streaks & pink hue globules blotch Arborizing / Spoke wheel like Leaf like Blue gray ovoid Multiple blue branched Shiny white blotches & structures areas nests gray vessels strands dots / globules Glomerular / White circles Brown circles Rosettes Brown dots Yellow scale Strawberry coiled vessels radially arranged pattern Ulceration Hairpin vessels with whitish halo Two component pattern Kissing nevus Structureless tan / pink pattern Nevi in skin type 1 Multi component pattern Symmetric Tiered globular pattern Spitz / Reed Starburst pattern Spitz / Reed Melanoma pattern: 1. Do not manifest any of the benign nevus patterns depicted on card 1 2. Usually display a multicomponent disorganized pattern with at least one melanoma specific structure depicted on (Card 3) 3. Can be structureless or featureless or blue-black in color (non-specific or feature-poor) 4. On sun-damaged skin they often appear as large lentiginous lesions with the patterns shown below 5. Seb K Milia like cysts Comedo like openings Fissures/sulci Fingerprint like structures Moth eaten Sharp demarcation Gyri / ridges and border sulci / fissures Hairpin vessels with whitish halo Melanoma on sun damaged skin 6. Other Angioma: Red lacunae Angiokeratoma: Red / blue / black lacunae Sebaceous hyperplasia: Crown vessels CCA: Vessels in serpiginous / string of pearls arrangement Step 2: Look for melanoma patterns & structures (Card 2&3) Multi component patternasymmetric Structureless brown Structureless: Blue black nodule Structureless: Pink / tan macule patchy peripheral pigmented Tan structureless areas islands or hyperpigmented foci with granularity Angulated line pattern Special locations Atypical network Angulated lines Negative network Atypical streaks Atypical dots and globules Regression structures Tan structureless areas Prominent skin markings Parallel ridge pattern Atypical fibrillar pattern Diffuse pigmentation with multiple shades of brown Milky red areas Multi-component pattern Melanoma specific structures multiple small hyperpigmented areas Atypical blotches Raised blue white structureless area Blue white veil Granularity / peppering Regression scarlike depigmentation and peppering Flat blue white structureless area Shiny white structures Atypical vascular patterns Pigmented follicular openings Annular granular pattern Rhomboidal structures Dark blotches and obliterated hair follicles Melanin inclusions Comma / curved vessels Dotted vessels Serpentine vessels Corkscrew vessels Polymorphous vessels Milky red areas / milky red globules Designed by Ralph P. Braun & Ashfaq A. Marghoob dermoscopedia.org No Yes Grey band Lentigo: melanocytic activation Brown band: Melanocytic proliferation Hemorrhage Fungus Pseudomonas dermoscopedia.org Brown regular: nevus Brown irregular: melanoma

10 While learning all the nuances & mastering dermoscopy you can rely on a simple new triage algorithm (to complement you visual acumen)

11 Find skin cancer! (including those that lack clinical ABCD)

12 Triage Amalgamated Dermoscopy Algorithm

15 Disorganized: BCC, SCC, MM

19 Organized lesions revealing any of the following: Need to R/O skin cancer Pattern Starburst Negative network Color Blue, black, gray Shiny white / white Vessels/ulceration

20 Starburst Pattern

21 Negative network

22 Blue, black, &

23 gray color

24 Shiny white structures (PD) White circles (PD or NPD)

25 Vessels

26 Ulceration

TADA results by lesion type and dermoscopic training Sensitivity Specificity Overall 94.8 72.3 Previous training Dermoscopy Yes 95.2 71.7 No 93.4 70.

29 TADA results by lesion type and dermoscopic training Sensitivity Specificity Overall Previous training Dermoscopy Yes No Lesion Type Melanoma (MM, MMIS, AMM, NM) BCC SCC Seborrheic Keratosis Dermatofibroma Hemangioma Nevus

30 3. Practice, Predict, Compare

31 Practice: My eyes are just as good - why not simply confirm that to be the case? At a minimum it will increase your confidence in your clinical acumen. Predict: Based on dermoscopic structures start predicting what the histopathology will show. At a minimum it will help you to find some cases that need further investigation (step sectioning) or identify specimens that may have gotten switched. Compare: Compare clinical/dermoscopy images with histopathology images/report A guaranteed method to skyrocket your learning curve

32 Histopathology not congruent with dermoscopy: Red flag that dx may not be correct!

33 Mark the area of concern on the submitted specimen Micro-punch Ink Suture Add clinical / dermoscopic image can help identify orientation and document the marked site

34 Histopathology not congruent with dermoscopy: Red flag that specimens may be mislabeled or switched! Excisional biopsy length 1.8cm Excisional biopsy length 2.3cm MMIS 0.95mm MM arising in a nevus

Dermoscopy bringing us back to our roots & reinforcing the synergy between clinical dermatology and dermatopathology The dermatologist is fortunate in being able to

35 Dermoscopy bringing us back to our roots & reinforcing the synergy between clinical dermatology and dermatopathology The dermatologist is fortunate in being able to study the clinical picture with his histologicallytrained eye and the microscopic picture with his dermatologicallytrained eye Unna PG. Histopathology of Skin Disease. 1894

36 How long will it take to see improvement? Dermoscopy: experts Dermoscopy: non-experts Kittler et al. Lancet Oncology 2002; 3: Clinical: without dermoscopy

Improved diagnostic accuracy after a 1-2 year learning period 25 20 15 10 Benign to Malignant Ratio 22.5 13.

37 Improved diagnostic accuracy after a 1-2 year learning period Benign to Malignant Ratio Terushkin V, et al. (2011) Arch Dermatol 146(3): Baseline Dermsocopy Year 1 Dermsocopy Year 2

38 4. Eureka The aforementioned will culminate in a Eureka moment: I cannot practice w/o dermoscopy! You will start to realize you are picking up on skin cancers you were previously missing You will come to realize that the Cochrane review is correct - your eyes are not just as good

43 2005

44 You will understand why your eyes are not just as good!!!

45 Your visual abilities are just as good for finding what? Clinically detected cancers Dermoscopically detected cancers

48 Thus, statements such as this are not accurate!

49 Thinking outside of the ABCD box Dermoscopy & Confocal

52 Dermoscopy is more accurate than the naked eye alone for the diagnosis of melanoma Meta-analysis including 9 prospective studies Dermoscopy improves sensitivity and specificity compared to naked eye Dermoscopy Naked eye Sensitivity 90% 71% Specificity 90% 81% Vestergaard ME, et al. Br J Dermatol. 2008;159(3):

53 Evidence based medicine!

56 Key factors in successfully integrating dermoscopy into your clinic Proximity Knowledge acquisition (the basics) Practice, Predict, Compare Eureka

57 Upcoming meetings American Dermoscopy Meeting, August 14-17, 2019 IDS World Congress of Dermoscopy, June 10-12, 2021

comedo-like openings (clods, brown or orange & circles) milia-like cysts (dots or clods, white) 1/29/18 Dotted vessels are also commonly seen in SCC

comedo-like openings (clods, brown or orange & circles) milia-like cysts (dots or clods, white) 1/29/18 Dotted vessels are also commonly seen in SCC Brown circles Dotted vessels are also commonly seen in SCC Step1 1. Nevus (unequivocal) 2. DF/IDN 3. BCC 4. SCC Network Patchy network Peripheral network & central hypopigmentation DF: network with central