Total body photography in high risk patients Doug Grossman, MD, PhD Department of Dermatology Huntsman Cancer Institute University of Utah Summer AAD F032 Practical Considerations for Patients with Melanoma or Dysplastic Nevi July 29, 2018
Declarations I have no financial interest in any commercial products related to skin (or nevus) photography I am not a consultant or speaker for any company that manufactures or distributes these products I have no conflicts of interest!!!
Goals for monitoring and early melanoma detection Identify high-risk patients Biopsy melanomas early Observe/follow nevi (but not melanomas) Avoid unnecessary biopsies / excisions
Who has increased risk for melanoma? Personal h/o melanoma (10x) Numerous nevi (2-4x) Clinically atypical nevi (2-4x) Family h/o melanoma (10-30x) (approx. 10% of melanoma patients) Predictors of high nevus counts >20 nevi on arms, age <50 Argenziano, Eur J Cancer Prev 2014 >5 nevi on right arm Echeverria, Br J Dermatol 2014
Individual lesions To biopsy or not to biopsy? Clinically benign Not-so-obvious Helicopter diagnoses
69-y/o female referred for suspicious lesion on breast A B C D 1 cm Dx: seborrheic keratosis
When confronted with numerous nevi What s the best approach?
This patient had a molectomy but Nevus-free skin contains vast reservoir of melanocytes that represent potential melanoma precursors Most melanomas (70-80%) don t arise from nevi Bevona, Arch Dermatol 2003 Goodson, Dermatol Surg 2011 Cymerman, JNCI 2016 Pampena, JAAD 2017
Melanoma detection in 3 dimensions 1-dimensional approaches Naked eye: ABCD criteria Dermoscopy Non-invasive imaging (confocal, multispectral) 2-dimensional approaches (Comparing lesions to each other) Signature lesions Ugly ducklings Comparative dermoscopy 3-dimensional approaches (Comparing lesions over time) Digital dermatoscopic monitoring Total body photography
Photography is the only way to document changes There are two paradigms for photographic monitoring Serial dermoscopic monitoring Baseline 1 st f/u visit 2 nd f/u visit Detect small changes in nevi Only monitor nevi that have been photographed May miss new nevi Can be laborious if many lesions Total body photography Baseline New lesion Detect new nevi Pre-existing nevi: confirm stable Pre-existing nevi: detect changes Stable lesions F/u visit
Number of lesions Nevus development over time Congenital nevi Common acquired nevi (No new nevi) Nevus regression 0 10 20 30 40 50 60 70 80 90 Age (in years)
Normal nevus growth patterns Peripheral dots Symmetric enlargement Maintain shape Maintain color Maintain pigment distribution Bajaj, JAMA Dermatol 2015
Expected changes Nevus Melanoma Gradual enlargement (<1 mm 2 per year)* Maintain same shape Maintain same pigment distribution Uniform darkening or lightening Uniform regression * Do NOT see monthto-month changes Rapid enlargement (>3 mm 2 per year)** Does not maintain same shape Change in pigment distribution Non-uniform darkening or lightening Non-uniform regression ** Month-to-month changes *, **Tschandl, Br J Dermatol 2015
Mole Mapping at the Huntsman Cancer Institute 2004 - present 3000 total patients Up to 25 photographs PH melanoma (1000) FH melanoma (450) >50 nevi (2000) Atypical nevi (2300) Photos: manual or semi-automated Commercial: encryption and archiving Storage: secure server Dedicated people Dedicated room
Initial visit 1. History 2. Full skin exam 3. Biopsy ugly ducklings 4. Full-body photography Each follow-up visit (6-12 months) 1 st f/u visit (3 months later) 1. History 2. Full skin exam 3. Confirm no suspicious changes (using photos) 4. Educate patient and partner on using photos 5. Copy of photos given to patient on flashdrive 1. Identify/assess any lesions of patient concern 2. Clinical exam 3. Dermoscopy of any suspicious lesions 4. Compare suspicious lesions to previous photos 5. Assess difficult-to-monitor areas (back, buttocks, post legs) for new and changed nevi
The Power of Photographic Comparisons
Role of photography in high risk patients Patient history Review melanoma risk factors Performing SSE with photos? Any new changing lesions seen? F/u intervals (6-12 m) Sun protection Monthly SSE with photos Recommendations Skin examination Complete skin examination Evaluate lesions of patient concern Look for signature lesions, ugly ducklings Dermoscopy of potentially suspicious lesions Consider biopsy of suspicious lesions Patient concern Physician concern Ugly duckling Changing asymmetric lesion New clinically atypical lesion New lesion in patient over age 50 Photographic review Side-by-side comparisons Identify new/changing lesions