Disclosure. Objectives. PAFP CME Conference Lou Mancano MD, FAAFP Reading Health System November 18, 2016

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1 PAFP CME Conference Lou Mancano MD, FAAFP Reading Health System November 18, Disclosure The speaker has no conflict of interest, financial agreement, or working affiliation with any group or organization. 2 Objectives Know when and how to use a dermoscope in clinical practice; Know how to identify structural features of melanoma and other skin cancers using a dermoscope; Use a dermoscope to diagnose some benign lesions without the need for a biopsy. **Please Remember to Complete Session Evaluation 3 1

2 ABCDE The ABCDE acronym (Asymmetry, irregular Borders, multiple Colors, Diameter >6 mm, Enlarging lesion) has been the primary clinical criteria for diagnosing suspected cutaneous malignant melanoma Early phase melanoma is difficult to identify as it can share clinical features of an atypical nevus Diagnostic accuracy rates using ABCDE range from 50-75%, indicating a need for additional diagnostic tools 4 Skin in Natural Light Under normal conditions, most natural light is reflected by the skin s stratum corneum Is difficult for the unaided eye to appreciate subdermal structures Reducing light reflection allows for better visualization of the epidermis, dermal-epidermal junction, and papillary dermal structures to about 2 mm below the skin surface 5 Dermoscopy Sometimes referred to as epiluminescence microscopy (ELM) A non-invasive tool to evaluate colors and microstructures of the epidermis, the dermo-epidermal junction, and the papillary dermis 6 2

3 Dermoscopy Helps see below the skin surface to differentiate melanoma and non-melanoma skin CA from some benign skin lesions After training, one study found the sensitivity of diagnosing melanoma improved from 74% with the unaided eye to 90% with a dermatoscope Aids in the decision-making process as to whether to perform a biopsy and can isolate suspicious areas within a lesion to guide biopsy 7 Dermoscopy Dermoscopic images can be photographed and stored 8 Dermoscopy Methods of reducing natural light reflection: Apply a non-polarized glass plate with immersion fluid directly to the stratum corneum Cross-polarization filters block surface glare, allowing light from deeper layers to become visible to the eye 9 3

4 Dermoscopes (Dermatoscopes) Hand-held types are fitted with an internal light source and usually a 10X magnifier Non-Polarized Light, contact Polarized Light, contact Polarized Light, non-contact 10 Contact Dermoscopy Requires contact and a liquid interface For most contact evaluations, 70% alcohol is recommended Fewer air bubbles Clear images Reduced bacterial contamination For nails and areas close to mucosal surfaces, gels (water soluble ultrasound gel) are recommended 11 Non-Polarized (NPD) Requires contact Superficial layers are better visualized than deeper layers Milia-like cysts and comedo-like structures are easier to recognize Blue, bluish-white and gray to grayish-white colors are often more conspicuous with NPD (than pink, red and white colors) 12 4

5 Seborrheic Keratosis (NPD) Comedo-like openings Polarized Dermoscopy Milia cysts NPD Photo taken by Ashfaq A Marghoob, MD, and Natalia Jaimes, MD 13 Bluish Colors on NPD Blue nevus Melanoma blue-white veil 14 Polarized (PD) Contact is not required A liquid interface and direct contact can improve image clarity Deep epidermis and papillary dermis are better visualized than superficial layers Pink, red and white colors are more conspicuous with PD (than are blue, bluish-white and grayish-white colors) 15 5

6 Pink and White on PD vs NPD Amelanotic melanoma (PD) Amelanotic melanoma (NPD) 16 NPD and PD are Complementary Polarized dermoscopy improves sensitivity for detecting skin cancer based on its ability to enhance the visualization of vascular, crystalline structures, and some pigment patterns Nonpolarized dermoscopy improves specificity by easier visualization of structures commonly seen in benign lesions, such as milia-like cysts in seborrheic keratosis 17 Dermoscopy Specifics Color Structure Dermoscopic Symmetry vs. Asymmetry Organized vs. Disorganized Patterns 18 6

7 Color Keratin is usually yellow Melanin color varies with its concentration and depth (black, brown, tan, gray, pink, blue) Vasculature is usually red, but thrombi can appear purplish or black Melanophages in the dermis are usually gray Collagen and fibrosis is usually white 19 Dermoscopy Colors yellow black brown tan gray pink blue 20 Color - Melanin Black melanin in the stratum corneum Brown melanin below the stratum corneum in dermalepidermal junction and papillary dermis 21 7

8 Melanin Gray color in upper dermal melanophages Gray-blue to deep blue in the deeper dermis (blue nevi) 22 Color - Vasculature Red vascularity (BCC, telangiectasias) Purplish-red vascular lesions (capillary nevi, angiokeratomas) 23 Color - Vasculature Thrombi can appear black to purple to red 24 8

9 Color - Collagen and Keratin White collagen seen in regression or scarring Yellow keratin usually in hyperkeratosis (verrucous keratosis) 25 Structures: Pigment Network (PN) The PN is an important feature of melanocytic lesions appearing like a reticular pattern of pigmented lines and hypopigmented holes Correlates histologically to the rete ridge pattern and to the distribution of melanin within the keratinocytes 26 Pigmented Network Patterns Thin layers of pigment cells over the dermal papillae appear as holes in the net Columns of pigmented cell in the rete ridges appear as the darker substance of the network 27 9

10 Pigment Network In benign melanocytic nevi, the PN is tan to brown and network lines thin and fade gradually at the periphery 28 Structures Dots (< 0.1 mm) focal accumulations of free melanin or highly pigmented melanocytes in the cornified layers of the epidermis Globules larger than dots (> 0.1 mm) and can create a cobblestone pattern Blotches - focal hyperpigmented areas that obscure underlying structures; can occur centrally or when symmetrical can cover much or all of a lesion 29 Structures - Homogeneous Homogeneous ( structureless ) area usually obscures some dots, globules or reticulations Often found in the central portion of benign lesions Can also be seen in some malignant lesions 30 10

11 Structures Dots Brown dots in a benign junctional nevus 31 Structures Globules Cobblestone brown and tan globules (compound nevus) represent nests of melanocytes at the dermal-epidermal junction and papillary dermis 32 Structures - Blotches Large concentrations of melanin throughout the epidermis, dermis, or both, seen in this melanoma 33 11

12 Symmetry and Asymmetry Symmetry has two parts: Dermoscopic symmetry refers to similar distribution of colors and structures on either side of an axis Visual symmetry refers to mirror image shape of the lesion You can have a visually symmetrically-shaped lesion with asymmetry in dermoscopic color and/or structures You can have a visually asymmetrically-shaped lesion with dermoscopic symmetry in color and/or structures 34 Symmetrical Shape and Pattern Symmetrical in color and structures Symmetrical in shape Benign nevus 35 Asymmetrical Shape and Pattern When split by one axis there is somewhat monaxial symmetry in shape and color, but with two axes, there is biaxial asymmetry in color more than shape This requires a biopsy Atypical nevus 36 12

13 Reticular A uniform network that thins at the periphery Compound Nevus Benign Patterns 37 Globular Diffuse globules throughout the lesion Dermal Nevus Benign Patterns 38 Benign Patterns Homogeneous Pattern characterized by a symmetrical structureless area without globules or reticulations Junctional nevus 39 13

14 Benign Pattern Combinations Homogeneous - Reticular hyper- or hypopigmented homogeneous center with a uniform reticular peripheral network Compound nevus Reticular-Globular Central globules with uniform network at the periphery or vice versa 40 Benign Pattern Combinations Homogeneous Globular Homogeneous structureless area with surrounding globules or vice versa 41 Malignant Patterns Reticular-Disorganized Network Network is non-uniform and often darker or thickened at the periphery Radial streaming 42 14

15 Malignant Patterns Disorganized Network Globules vary in size and shape and are asymmetrically distributed Thicker reticular lines or broadened network Pseudopod or bulbous projections at the edge of the lesion Pseudopods Broadened network 43 Malignant Patterns Homogeneous-Disorganized Reticular Network No obvious network or globule pattern Color and pattern is disorganized Broadened network Radial streaming Radial streaming 44 Malignant Features Radial Streaming parallel linear streaks or streaming extensions at edge of lesion often represent the radial growth phase of melanoma Radial streaming 45 15

16 Malignant Features Crystalline or crysalislike structures (only seen with PD) 46 Malignant Features Off-center blotches Disorganized larger areas of pigment Blue-gray or blue-white veil 47 Malignant Features Negative pigment network, loss of reticular pigment Negative network requires biopsy 48 16

17 Malignant Features Blue-white veil Bluish-gray to bluishwhite haze over an area of the lesion (seen in the dotted square) Radial streaming 49 Malignant Features Atypical globules Dotted vessels Serpentine vessels Dotted vessels 50 Malignant Features Atypical broadened network Negative network Atypical peripheral globules Atypical broadened network 51 17

18 Basal Cell Carcinoma (pigmented) Blue ovoid masses larger discrete pigmented round, oval or bullet-shaped blue structures characteristic of BCC 52 Basal Cell Carcinomas (pigmented) Spoke-wheel areas Bluish ovoid structures with radial projections are called spoke-wheel areas 53 Basal Cell Carcinomas (pigmented) Leaf-like areas Smaller gray, brown or blue discrete bulbous structures unassociated with a pigment network seen toward the edges of pigmented BCCs, often with blue ovoid masses Some may appear as structureless areas 54 18

19 Basal Cell Carcinoma Superficial BCC with crystalline or chrysalis structures 55 Vascular Patterns 56 Vascular Patterns Treelike vessels are thicker, arborizing vessels Often seen in basal cell carcinomas 57 19

20 Vascular Patterns Corona vessels are thinner and less curved than arborizing vessels Generally seen in sebaceous gland hyperplasias 58 Vascular Patterns Comma-shaped vessels parallel to skin surface and appear as short curved vascular structures often visible in benign compound or dermal nevi 59 Vascular Patterns Point vessels are short capillary loops visible on end as pinpoint dots seen in all types of melanocytic tumors, actinic keratosis, Bowen disease, Spitz nevi, SCC and inflammatory lesions 60 20

21 Vascular Patterns Hairpin vessels are long capillary loops of thicker tumors related to angiogenesis at the border of melanomas, but also in squamous cell carcinoma, keratoacanthoma, and seborrheic keratosis 61 Vascular Patterns Glomerular-like larger reddish dots made up of curled up capillaries seen in Bowen s disease, SCC and stasis dermatitis 62 Vascular Patterns A combination of vessels (point, corkscrew, corona, pink areas) seen in melanoma. Note the pigment and pink color pattern

22 Break 64 Light brown pigmented network in a benign appearing pigmented nevus 65 Arborizing vessels in basal cell carcinoma 66 22

23 Brown pigmented network in a benign appearing melanocytic nevus 67 Melanoma with broadened network at the periphery and a whitish veil (*) 68 Network of somewhat uniform pinpoint and perifollicular vessels in an actinic keratosis 69 23

24 In situ melanoma with brown, black and gray color distribution, broadened pigment network not thinning at the periphery, radial streaming, and a whitish veil (*) 70 Atypical (dysplastic) nevus with irregular pigment network and a whitish veil (*) 71 Melanoma with pseudopods at the periphery and a whitish veil (*) 72 24

25 Benign appearing melanocytic nevus with globular pattern 73 Grouped glomerular-like point vessels in a squamous cell skin carcinoma 74 Benign melanocytic nevus with homogeneous center and regular distribution of dots at the periphery 75 25

26 Varied color globules in invasive melanoma correspond to nests of melanocytes at the junction in the papillary dermis (tan and brown), melanin storage in melanophage clusters in the papillary dermis (gray), and reddish-brown globules representing cell nests with increased vascularization 76 Invasive melanoma with white and gray areas (**), different sized pigmented dots (*) and globules (O). Melanophages and/or atypical melanocytes in the dermis correlate with blue-gray or slate blue dots typically found in pigmented lesions undergoing regression 77 Depigmentation in a melanocytic nevus with reduction of pigment that corresponds to pigmented areas lighter than other areas within the nevus. 78 In contrast to hypopigmented areas, depigmented areas completely lack pigment. 26

27 Pigment asymmetrically and negative pigment network in the lower periphery of this melanoma. Central grayish veil. Pink color indicates increased vasculature and some deep dermal pigment. 79 Shiny white "chrysalis structures" in the left periphery of this melanoma. Thick, short, bright, whitish linear structures seen with polarized dermoscopy in melanoma, Spitz nevus, dermatofibroma and basal cell carcinoma. 80 Correspond to changes in the composition and orientation of collagen. Milialike cysts (*) and comedolike openings (O) in seborrheic keratosis seen best with non-polarized dermoscopy

28 82 Thank You Please Remember to Complete Session Evaluation 83 References Marghoob A, Usatine R, Jaimes N. Am Fam Physician Oct 1;88(7):

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