Dr Amanda Oakley. Dermatologist Dept of Dermatology, Health Waikato Adjunct Associate Professor, Waikato Clinical Campus

Transcription

1 Dr Amanda Oakley Dermatologist Dept of Dermatology, Health Waikato Adjunct Associate Professor, Waikato Clinical Campus 14:00-16:00 WS #14: Dermoscopy Part 1

2 Skin Lesions and Dermatoscopy 16 August 2018 Christchurch GPCME Amanda Oakley Dermatologist, Dept of Dermatology, Health Waikato Adjunct Associate Professor, Waikato Clinical Campus Website Manager, DermNet New Zealand Specialist Dermatologist, Tristram Clinic Diagnosing Dermatologist, MoleMap NZ Director, New Zealand Teledermatology Tristram Clinic

3 Declaration of conflict of interest I diagnose for MoleMap NZ Thanks for many images I am Founder and Chief Editor of DermNet NZ Sponsored by PHARMA I have been on various advisory boards over the years but not relevant to this talk

4 This workshop Is not intended to make you an expert Expects you to take a history and to undertake total body skin examination 4

5 Content of workshop Course context Pre-test Introduction to dermatoscopy Clinical features of pigmented skin lesions Dermatoscopy of pigmented skin lesions Interactive exercises 5

6 6

7 Melanoma Standards Standard 1.1 Patients are offered evidence-based information on risk factors, prevention and detection of melanoma early Avoid sunburn and adopt UV protection (physical methods complemented by sunscreen) Strongly discourage use of sunbeds Advise all adults, particularly those aged 50 and over to: Regularly examine their skin Get someone else to check areas difficult to see Seek advice from a doctor about suspicious lesions. Total lack of sun exposure not advisable without vitamin D supplementation

8 Risk factors are age, prior melanoma / skin cancer / sun damage, many/large moles But two-thirds melanoma in average-risk subjects Nearly all skin cancer relates to UVR exposure Protect skin from UVR (sun, indoor tanning beds) Behaviour, clothing, SPF 50+ sunscreen Teach self skin-examination If risk factors, annual full skin check If many moles, digital dermatoscopic surveillance 8

9 Strongest predictors of invasive melanoma in > 65 yr: 2.3 x risk than < 45 Men: 2.1 x risk than women Queenslanders Skin doesn't tan: 4.8 x risk than if tan deeply At age 21 with many moles: 4.4 x those with 0 If >21 lesions treated, 2.5 x higher risk than those who had none treated 9

10 Primary prevention Target: All ages Fair skinned people People who work outdoors People with existing sun damage 10

11 Vitamin D and sun exposure 11

12 Estimate patient s risk of melanoma / NMSC Risk factor widget on BPAC Stay alert to incidental skin lesions Melanoma + NMSC Carry out full skin check Determine what s normal for the patient (moles, freckles, seborrhoeic keratoses, angiomas) 12

13 Take a history Skin cancer, immune suppression (drugs, disease), strong family history of melanoma (2+ < 40 yrs) Examine face and hands for actinic keratoses, solar lentigines Examine all skin for mole number (> 100), pattern Large moles, small dark moles, odd-looking moles Large congenital melanocytic naevi If > 20 cm, send to specialist for assessment 13

14 Melanoma Standards Standard 4.1 Investigation, Diagnosis and Staging Patients have access to a clinician trained in: Early detection and diagnosis of melanoma, including the use of dermatoscopy Surgical skills to undertake excision and direct closure of in-situ or thin melanoma The triage and referral of patients with lesions of uncertain diagnosis, thicker melanoma and lesions on sites where surgery is difficult.

15 Today s workshop is an introduction to dermatoscopy; it takes practice to be good at it Digital dermatoscopy (images) enhances skill Aids referral + clinicopathological correlation Automated devices should not be relied upon Surgical skills also take training + practice If you are not doing lots of surgery, refer to someone who is 15

16 Other resources Please join MelNet DermNet NZ Dermatoscopy Teledermatology for suspected skin cancers 16

17 Not always easy 17

18 Pre-test 10 images of pigmented skin lesions Decide if benign or malignant Select a diagnosis 10 seconds for each case 18

19 Lesion 1 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 19

20 Lesion 2 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 20

21 Lesion 3 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 21

22 Lesion 4 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 22

23 Lesion 5 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 23

24 Lesion 6 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 24

25 Lesion 7 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 25

26 Lesion 8 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 26

27 Lesion 9 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 27

28 Lesion 10 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 28

29 Introduction to dermatoscopy 29

30 This workshop is interactive Option A Option B 30

31 Who has their own dermatoscope? I have my own I don t have my own 31

32 What is dermatoscopy? = Dermatoscopy, epiluminescent microscopy Skin examination using: Magnification Good light Means to reduce surface reflection Contact fluid film Polarising filter Improves diagnostic accuracy in expert hands Confirmed by numerous clinical trials 32

33 Why magnify? 34

34 Why reduce surface reflection? No polarisation Polarisation 36

35 Dermatoscopes 37

36 This workshop is interactive Option 1 Option 2 Option 3??? 38

37 Option 4 None of the options are true: I don t know Not applicable 39

38 My dermatoscope is: Polarised Unpolarised A? B? Both? 40

39 My dermatoscope is: Contact Non-contact A? B? Both? 41

40 I have photodermatoscopy: Yes No A? B? Both? 42

41 Which dermatoscope? Depends on budget, interest, digital imaging Choices: Polarised, unpolarised or both Contact or non-contact Ability to attach to a camera Lens size and quality Portability Charger: AC, USB, dock 43

42 Non-contact devices Speedy review of entire skin surface Polarised view

43 Contact devices Add fluid Better quality Best for imaging Polarised and non-polarised options 46

44 Polarised vs unpolarised Both have liquid interface and lens in contact with the skin

45 How to use non-contact dermatoscope Takes practice to focus on skin lesions Allows a quick review of many lesions 50

46 How to use contact dermatoscope Tedious but higher quality Apply fluid to lesion Clean lens between lesions Clean lens between cases 51

47 Photography = digital dermatoscopy Camera Adapter(s) Suitable dermatoscope Archiving system Software suitable for sharing images 53

48 Why take photos? Clinical purposes The record Referral: required for HSCan melanoma referrals Clinicopathological correlation Education Yours Someone else s Research, publication 54

49 Smartphone + device Handyscope, Veos HD1, HD2 For iphone 4, 5, 6 Dermlite DL1, DL2, DL3 For iphone 4, 5, 6, 6+, 6s; ipod Touch; ipad 3, 4, air, mini; Galaxy S3, S4, S5 S6 Heine ic1 For iphone 5, 6 DermLite Hüd For smartphones 55

50 56

51 DermEngine software 57

52 Dermatoscopy training requires: Experience in skin history / examination Elementary course e.g., today s Reference books, articles, online resources A dermatoscope immediately to hand A camera to record lesions of interest Continued practice 58

53 Training in dermatoscopy Online modules: Apps Textbooks International Diploma of Dermatoscopy MMed (Skin Cancer) Program, U of Queensland Healthcert Skin Cancer Certificate Courses Skin Cancer College Australasia Certificatehttp:// 59

54 itunes App Store 60

55 Virtual Dermatoscope 61

56 When to use dermatoscopy All the time! Pigmented and non-pigmented lesions Benign, malignant and of uncertain significance Inflammatory dermatoses Psoriasis, eczema, lichen planus, lupus Infestations Head lice, scabies 62

57 Which of these has scabies? A? B? Both?

58 Which of these has scabies? A? B? Both?

59 Dermatoscopy of burrow

60 Skin examination 66

61 I d like a skin check Take a history Assess risk factors for skin cancer Identify lesion(s) of concern To patient, significant other, health professional Onset, duration, behaviour Effect of previous treatment 67

62 Risk factors for melanoma/nmsc Age, esp. >50 years Previous melanoma Previous keratinocytic skin cancer (BCC, SCC) Many moles Large moles Familial melanoma (2+ young, close relatives) Sunburns (melanoma, BCC) Chronic exposure to UV (AKs, SCCs) 68

63 Skin examination Good light & magnification Whole body Lesion location, distribution, morphology Size Shape Surface Structure Colour Ugly duckling? Dermlite Lumio & Lumio S 69

64 Photograph the lesion Anatomic Close-up 70

65 Take dermatoscopy images Clean lenses, dry carefully Apply fluid to lesion surface Spacer plate out, in contact with lesion, focus & capture 71

66 Dermatoscopy images Polarised Unpolarised 72

67 Dermatoscopy images Polarised Unpolarised 73

68 Still not sure? Excise with 2-mm margin 74 Histopathology: seborrhoeic keratosis

69 Pigmented skin lesions Melanocytic Naevus + melanomas Epithelial Seborrhoeic keratosis + BCC / SCC Vascular Angioma + haemorrhage Other Dermatofibroma 75

70 Benign lesions Rarely need excision. Exceptions: If malignancy cannot be excluded Significant symptoms Cosmetic reasons Benign lesions show symmetry: Single or multiple patterns Assess structure, colour and border (not shape) 76

71 So, which benign lesions: Should be referred? Excised as a precaution? Followed up? Ignored? It isn t always easy! 77

72 High Suspicion of Cancer HSCan (melanoma) Ministry of Health idea Initially for triage Later will be for referral 78

73 Which has red flag A? A? B? Both? 79

74 Red flag A : asymmetry Speckled lentiginous naevus Melanoma in situ 80

75 Which has red flag B? A? B? Both? 81

76 Red flag B : border Melanoma in situ Benign melanocytic naevus 82

77 Which has red flag C? A? B? Both? 83

78 Red flag C : colour Nodular melanoma 2.5 mm Melanoma in situ 84

79 Which has red flag D A? B? Both? 85

80 Red flag D : different SS melanoma 2.5 mm Seborrhoeic keratosis 86

81 Red flag D : different SS melanoma 3 mm Seborrhoeic keatosis 87

82 Which has red flag E? A? B? Both? 88

83 Which has red flag E A? B? Both? 89

84 Evolving: lesion A Seborrhoeic keratosis 2014 Seborrhoeic keratosis

85 Evolving: lesion B Benign naevus 2012 Benign naevus

86 Evolving: lesion B Benign naevus 2012 Benign naevus

87 Evolving lesion : melanoma in situ 93

88 Evolving lesion 2010: monitored 2011: melanoma in situ 94

89 Dermatoscopy of benign lesions No Chaos Symmetry of structure Symmetry of colour Symmetry of border One pattern, 2 concentric/regular patterns or 3 concentric patterns 95

90 Dermatoscopy of malignant lesions Chaos Asymmetry of structure Asymmetry of colour Asymmetry of border abruptness More than one pattern + One of the following clues: 1. Eccentric structureless zones, any colour 2. Gray circles, lines, dots, clods 3. Black dots or clods at periphery 4. Focal pseudopods or radial lines at periphery 5. White lines 6. Thick reticular lines 7. Polymorphous vessels 8. Parallel lines on the ridges (acral lesions only) 9. Large polygons 96

91 Chaos & Clues poster See Melnet website Provided by A/Prof Cliff Rosendahl 97

92 Modified pattern analysis Descriptive dermatoscopy 98

93 Dermoscopic pattern analysis Skin lesions are made up of structures: lines, dots/clods & structureless zones of varying colours... Structures forming neat patterns = naevi Structures disordered / chaotic = cancer 99

94 Patterns of lines 100

95 Clods Cobblestone pattern Globular or brown clod pattern 102

96 Patterns of dots Grey Red 103

97 Structureless patterns Brown (1 component) Skin coloured (2 components) 104

98 Complex patterns in naevi Structureless in structureless Structureless in dot/clods 105

99 Complex patterns in naevi Concentric patterns Repeating pattern 106

100 Disordered pattern in melanoma 107

101 Melanocytic lesions Naevi Melanoma 108

102 Melanocytic naevi Benign proliferation of melanocytes Naevocellular naevus Forming nests, chords, strands Congenital, tardive or acquired Histological classification (Ackerman) Congenital (superficial, superficial and deep), blue, combined, dermal / Unna / Miescher, halo / Sutton, recurrent, Clark, Spitz, Reed Junctional, compound, dermal 109

103 Junctional naevus: histology 110

104 Junctional naevus: dermatoscopy Sometimes a central area of dermal naevus is seen 111

105 Compound naevus: histology 112

106 Compound naevus: dermatoscopy 113

107 Dermal naevus: histology 114

108 Dermal naevus: dermatoscopy 115

109 Melanocytic naevi Congenital naevus Giant >40cm, large >20cm, medium >1.5cm, small Various clinical types Tardive naevus Appears in childhood/adolescence and evolves Similar pathological features to congenital naevus Acquired naevus Later onset, more superficial Follow immunosuppression or sun exposure 116

110 Which lesion is congenital? A? B? Both? 117

111 Both are true congenital naevi Large, distinctive lesions Present at birth A medium-sized >1.5 cm & <20 cm B giant-sized >40 cm

112 Which lesion is congenital? A? B? Both? 119

113 A is congenital True congenital naevus Childhood-onset tardive naevus Terminal hair indicates lesion was present at birth or during childhood (developmental) 120

114 Childhood-onset or tardive naevi Onset prior to puberty Sun has minor role A is common mole B is annular or eclipse naevus often found in scalp

115 Blue naevus Often deep blue May be grey, skin-coloured, brown Dermal spindle-shaped dendritic melanocytes 122

116 Blue naevus: histology 123

117 Blue naevus: dermatoscopy 124

118 Which is blue naevus? A? B? Both? 125

119 Dermatoscopy Angioma Blue naevus Clods pattern (lacunar) Structureless pattern (homogeneous) 126

120 Papillomatous dermal naevus (Unna) Often on trunk Soft, protruding mole Skin-coloured, brown, black Develops from flat naevus 127

121 Non-papillomatous dermal naevus: (Miescher) Dome-shaped nodule on face Skin coloured to dark brown May have terminal hair Histology: dermal melanocytes 128

122 Which is dermal naevus? A? B? Both? 129

123 Dermatoscopy of dermal naevi Unna naevus Miescher naevus Cobblestone pattern (clods) Structureless pattern (+ vv) 130

124 Acquired naevus = Clark naevus Trunk, prox. limbs Any colour (pink, brown, black) Round or oval Histology of larger lesions dysplastic Superficial, flatt(ish) 131

125 Naevus on face Look for holes Hair follicles Sweat ducts No pigment Pseudonetwork 132

126 Acral naevus (palm/sole) Ridges and furrows Pigment in furrows 133

127 Which is facial naevus? A? B? Both? 134

128 Dermatoscopy of special sites Facial naevus Acral naevus (plantar) Pseudoreticular: skin coloured clods Parallel lines (+ lattice-like) 135

129 Eccrine ducts 136

130 Signature naevi* People often have several of similar type More obvious in fair skinned people with many moles Typical for the individual Solid pink Solid brown Lentiginous Perifollicular hypopigmentation Eclipse Cockade *Bolognia 137

131 Patient with many naevi 138

132 Solid brown naevus Structureless, 1-2 colours 139

133 Solid pink naevus Regular vascular pattern 140

134 Lentiginous signature naevus Reticular, structureless centre 141

135 Perifollicular hypopigmentation Reticular, hypopigmented clods 142

136 Eclipse naevus 2 patterns (reticular + structureless) 143

137 Cockade naevus 3 patterns (reticular + structureless + clods) 144

138 Cockade means? A knot of ribbons worn on a hat A targetoid naevus A? B? Both? 146

139 Cockade Hungary Brazil Argentina France 147

140 Funny-looking naevi Atypical naevus Benign or melanoma! Atypical Spitz naevus Benign or melanoma! Dysplastic naevus Benign or melanoma! MELTUMP (Melanocytic tumour with uncertain malignant potential) Benign or melanoma! STUMP (Spitzoid tumour with uncertain malignant potential) Benign or melanoma! SAMPUS (superficial atypical melanocytic proliferation) Benign or melanoma! 148

141 Atypical naevus = uncertain biology 149

142 Atypical naevi: dermatoscopy 150

143 Which is benign? A? B? Both? 151

144 Dermatoscopy helps if uncertain Benign compound naevus Melanoma in situ B has greater asymmetry of structure or Chaos 153

145 Melanoma Malignant neoplasia arising from melanocytes In situ or invasive Sometimes, very difficult to diagnose Clinically, dermatoscopically, histologically Most important prognostic factor Breslow thickness 154

146 Melanoma Most lesions (?70%) de novo A few arise within naevi Congenital, tardive, acquired Diagnosed by appearance or behaviour Observed change In flat lesions, dermatoscopic change seen long before clinical change In nodular lesions, change often observed by patient 155

147 Observed change

148 Clinical subtypes of melanoma Lentigo maligna melanoma Lentiginous melanoma Superficial spreading melanoma Nodular melanoma Acral lentiginous melanoma Desmoplastic melanoma Mucosal melanoma Naevoid melanoma Animal melanoma Non-cutaneous melanoma 157

149 Clinical ABCD rule for melanoma Asymmetry of shape Border irregularity Colour variability Diameter >6 mm Evolving For lay people to detect melanoma Features may not apply to early melanoma or nodular melanoma 158

150 Clinical A(B)CD rule for melanoma Asymmetry of structure (Border irregularity) Colour variability Different 159

151 Ugly duckling sign 160

152 ABCD+. Which is melanoma? A? B? Both? 161

153 Dermatoscopy Congenital naevus Melanoma in situ Less disordered More disordered 162

154 Which is melanoma? A? B? Both? 163

155 Both reported as melanoma in situ 164

156 Blue colour suggests invasion 165

157 Clinicopathological correlation Check lab report against clinical images Is the pathology diagnosis consistent with your clinical diagnosis? If not, contact the pathologist This needs to be done promptly 166

158 Histology melanoma in situ Revised report: Invasive melanoma, 1.8 mm thickness 167

159 Pigmented non-melanocytic lesions Solar lentigo Seborrhoeic keratosis Keratinocytic cancer BCC, SCC 168

160 Solar lentigo Circumscribed light brown macule May develop into seborrhoeic keratoses In sun-damaged skin Melanin in basal keratinocytes Melanocytes normal or increased number Elongated rete ridges 169

161 Solar lentigo 170

162 Solar lentigo Sharp edge Structureless, yellowish 171

163 Solar lentigo Moth-eaten edge Subtle structures 172

164 Seborrhoeic keratoses Skin coloured, yellow, brown, black Smooth to verrucous Irregular structure Flat or thickened Very variable in appearance Stuck-on 173

165 Seborrhoeic keratoses 174

166 Seborrhoeic keratosis Stuck on, warty Orange clods, curved thick lines 175

167 Seborrhoeic keratosis Yellowish, greasy White clods 176

168 Seborrhoeic keratosis Yellowish, greasy White (& orange) clods 177

169 Seborrhoeic keratosis Thick curved lines 178

170 Which is solar lentigo? A? B? Both? 179

171 Pseudoreticular pattern in both Solar lentigo Melanocytic naevus Moth-eaten Roundish 180

172 Which is seborrhoeic keratosis? A? B? Both? 181

173 A is seborrhoeic keratosis Seborrhoeic keratosis Melanoma Easy! The seborrhoeic keratosis is scaly / warty 182

174 Which is seborrhoeic keratosis? A? B? Both? 183

175 B is seborrhoeic keratosis Dermal papillomatous naevus Seborrhoeic keratosis Discontinuous clods Interlinked clods + thick lines 184

176 Is precise diagnosis important? No if both are benign! Dermal papillomatous naevus Seborrhoeic keratosis 185

177 Does it wobble? Yes: melanocytic naevus No: seborrhoeic keratosis

178 Not always easy Seborrhoeic keratosis Melanoma Both can have have irregular and complex structures 187

179 Keratinocytic cancers Basal cell carcinoma Locally destructive On hair-bearing skin only Various types: Nodular Superficial Morphoeiform Fibroepithelial Infundibulocystic May be pigmented Actinic keratoses Rough white lesions on erythematous base May be pigmented SCC in situ Red scaly plaque May be pigmented Invasive SCC 188

180 Basal cell carcinoma Slow growing tumours on any site Locally destructive Early ulceration & bleeding May be pigmented Various subtypes: Nodulocystic Micronodular Morphoeic / sclerosing Ulcerative Superficial Basisquamous 189

181 Basal cell carcinoma 190

182 Dermatoscopy of basal cell carcinoma Irregular, bleeding, growing Irregular, bleeding, branched red lines 191

183 Dermatoscopy of Pink, shiny, enlarging basal cell carcinoma Peripheral dirty pigment, red branched lines 192

184 Actinic / solar keratosis Fluctuating small scaly plaques on areas chronically exposed to sunlight (face, hands) Tender, red or brown superficial lesions Variable adherent scale or horn Only on other sites when face and hands are badly affected Uncommon in darker skin types Uncommon in indoor workers 193

185 Actinic keratoses 194

186 Pigmented actinic keratosis Scaly irregular tender patch Strawberry + superficial network of broken-up lines 195

187 Strawberry Yellow dot within white circle with curved red lines 196

188 SCC in situ / intraepidermal ca One or more slowly-enlarging, red to brown, irregular plaques On any site May ulcerate or bleed Scale is prominent Bowen disease Often confused with eczema or psoriasis 197

189 SCC in situ All 4 of these were all found on the same patient s trunk and limbs 198

190 SCC is / IEC Irregular red scaly plaque Dotted blood vessels 199

191 SCC is / IEC Irregular red/brown scaly plaque Dotted blood vessels, may b in rows like the pigment 200

192 Invasive SCC Usually arise from actinic keratosis or IEC Fast-growing indurated, tender plaques or nodules Variable scale, horn and ulceration Variable differentiation: Keratoacanthoma Microinvasive disease Well differentiated Moderately well Undifferentiated Anaplastic 201

193 Invasive SCC 202

194 Squamous cell carcinoma Tender scaly growing nodule Central scale, white periphery 203

195 Squamous cell carcinoma Ulcerated tender growing nodule Central ulcer, white circles, white periphery 204

196 Which is BCC? A? B? Both? 205

197 Dermatoscopy Pigmented BCC 0.4 mm amelanotic melanoma Irregular peripheral pigment Small focus of pigment network 206

198 Which is BCC? A B A? B? Both? 207

199 Dermatoscopy Dermal naevus Nonpigmented basal cell carcinoma Structureless + terminal hairs Branched red lines + scale + ulcer 208

200 Which is BCC? A? B? Both? 209

201 Dermatoscopy Angioma Pigmented basal cell carcinoma Purple clods Irregular clods + dirty dishwater 210

202 Dirty dishwater 211

203 Dirty dishwater Irregular leaf-like clods and dots, grey-brown colour 212