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DERMOSCOPY 50 SKIN CANCERAdvances in the understanding of molecular pathogenesis have lead to improved survival.

52 MELANOMAcfDNA can provide a useful snapshot of the BRAF and NRAS melanoma tumor genotype, may be useful to assess tissue biopsies for the markers

Dermoscopy: The dermatologist’s stethoscope

W ith the incidence of skin cancers still on a steady rise, the timely detection and appropriate treat-

ment and management of melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) has never been more urgent.

Beyond the dermatoscope, the con-tinued research and development of other noninvasive optical imaging techniques has led to a number of variably effective diag-nostic approaches.

“Dermoscopy is a type of skin cancer screening technology that enables the physician to view the detailed structures of the lesion in question much more closely,” says Alexander Witkowski, M.D., Ph.D., of the department of dermatology at the University of Modena & Reggio Emilia.

“With up to 10-20x magnification, the dermatoscope allows us to see both the surface and subsurface structures of lesions and is used as a basic filter to check the basic dermatoscope criteria (i.e., asymmetry, round structures and/or pres-ence of blue-grey structures) of pigmented lesions,” he adds. He also works in the Vet-erans Hospital department of dermatol-ogy, Wroclaw, Poland, and Sportmedi-cum Skin Cancer Clinic, Krakow, Poland.

Although major technological advances in optical imaging techniques over the last two decades have resulted in significant improvement in the recognition of suspi-cious pigmented lesions, experts say that the dermatoscope remains an irreplacea-ble tool in the armamentarium of dermatol-ogists to more closely view and accurately assess the pigmented lesion under scrutiny.

“For the foreseeable future, I do not anticipate anything to be able to replace dermoscopy as the dermatologist’s steth-oscope,” says Eric Tkaczyk, M.D., Ph.D., F.A.A.D., director of the Vanderbilt Translational Skin Imaging Clinic.

“The dermatoscope offers an immedi-ate image that provides much more infor-mation than you can get with your stand-ard physical exam, enabling physicians to dramatically increase both their sensi-tivity and specificity when evaluating sus-picious pigmented lesions,” he adds. Dr. Tkaczyk also is assistant professor of der-matology at Vanderbilt University Medi-cal Center, assistant professor of Biomed-ical Engineering at Vanderbilt University, and attending Dermatologist at the Nash-ville VA Medical Center, Nashville, Tenn.

As more advanced imaging and other noninvasive diagnostic techniques con-tinue to emerge, Dr. Tkaczyk believes that there will be an increase in the utilization of these other innovative techniques includ-ing some that interface with dermoscopy, such as non-dermatologist assessment of dermoscopic lesions (i.e. artificial intelli-gence and Tele-Health).

To date, the strongest data gathered from clinical studies is on RCM. Compared to other emerging techniques, this data has sig-nificantly helped the technology overcome once challenging issues including reim-bursement from Medicare, Medicaid, and other insurances, as well as expedite the pro-cess of the technology’s widespread imple-mentation and integration into practice.

In the right hands, the specificity and sensitivity of RCM are both very high at approximately 70% and 95-97%, respec-

tively, in dermoscopically equivocal lesions. Compared to RCM, all of the other technol-ogies currently available do not approach such high specificity and sensitivity.

“RCM gives you a full view of the suspect lesion, up to 8mm x 8mm, with submicron resolution so you can see individual details of individual cells,” Dr. Tkaczyk says.

Apart from past reimbursement issues, another pivotal barrier that has kept RCM away from the average dermatologist in the United States and has hindered the tech-nology from moving forward and being readily available was that there weren’t any appropriate training programs in place that would teach dermatologists how to use the technology properly. According to Dr. Wit-kowski, using the device is relatively easy but correctly interpreting the images can take some time to learn and master. Striping is a recent major development

in RCM technology that allows for a much quicker generation of images, up to 50% faster than the previous software used. This would save valuable time for both physician and patient, Dr. Witkowski says.

OCT is another technology that has also proven to be useful in diagnosing some lesions. Having a depth view of approximately 1 mm to 2 mm (many times deeper than RCM) and generating images at lower resolution, OCT technology is helpful in identifying BCC but less appro-priate for detecting melanoma amongst melanocytic nevi. The imaging process works very quickly, accurately diagnos-ing BCC within 30 seconds. Viewing the depth of a lesion can help the clinician quickly determine whether the lesion is a superficial BCC or a deeper lesion such as

ILYA PETROU, M.D. | Staff Correspondent

The dermatoscope remains the diagnos-

tic tool of choice for the quick and accu-rate imaging of pig-

mented skin lesions.

The advent of other imaging tools, includ-

ing RCM and OCT, has proven to be

beneficial to dermatologists.

These tools have increased speed and precision in diagnos-

ing suspicious pigmented lesions.

Quick TAKES

DermatologyTimes®MARCH 2019

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DermatologyTimes® MARCH 2019

an early stage nodular BCC. “Technologies such as RCM and OCT can be ideally used

in those cases that are not crystal clear upon first assessment with a dermatoscope and can help to differentiate morpholog-ically between the telltale characteristics of borderline lesions with a very high sensitivity and specificity,” Dr. Witkowski says.

Other techniques such as multi-spectral imaging or Raman spectroscopy provide different information. They give informa-tion about the biochemistry of the viewed lesion. According to Dr. Tkaczyk, spectroscopy techniques yield valuable information on the chemical changes that occur well in advance of any structural changes that one would see with histopathology sections. How-ever, the data on existing devices shows the specificity to be around 10-40%, depending on the publication. Well-designed large mul-ticenter clinical studies on these spectroscopies are few and far between, underscoring the tendency for popularity of RCM.

“One current focus of industry is to combine the strengths of technologies to overcome each of their individual weaknesses, as well as making these devices cheaper and more portable. Very soon, we will see the advent of combination devices integrat-ing OCT and RCM, or dermoscopy and RCM in one single device. I believe the symbiosis of multi-modal imaging is really where the future lies in optimal skin cancer screening technol-ogy,” Dr. Tkaczyk says. �

Disclosures: Neither Dr. Tkaczyk or Dr. Witkowski report any rele-vant disclosures.

Eric Tkaczyk, M.D., Ph.D., F.A.A.D., and Melanie Patterson, LPN, providing noninvasive confocal imaging in the Vanderbilt Dermatology Imaging Clinic for a pigmented lesion of the face.

CME ACCREDITATION STATEMENT

This activity has been planned and

implemented in accordance with the

accreditation requirements and policies of

the Accreditation Council for Continuing

Medical Education (ACCME) through

the joint providership of the American

Society for Dermatologic Surgery and

Masters Program in Laser Education. The

American Society for Dermatologic Surgery

is accredited by the ACCME to provide

continuing medical education for physicians.

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