" New methods to diagnose changing moles"

Zsolt B. Argenyi, M.D.

Professor of Pathology & DermatologyDirector of the Pigmented Lesion Clinic

and Dermatopathology

University of Washington Medical CenterSeattle, WA, USA

Why to Strive for an Early Diagnosis?… and some more statistics

1. Long term survival is greater than 90% with thin (<1mm) melanoma.

2. Long term survival is 50-90% with thick (>1mm) melanoma

3. Long term survival is 20-60% with lymph node involvement

4. Long term survival is less than 10% with distant metastasis.

Diagnosis in early stages good survival

Some Encouraging News

65% of patients are diagnosed with localized disease

Goal

Better patient profiling

Improved identification techniques

Earliest possible diagnosis

Improved identification techniques

Skin self-examination Dermoscopy

Total body skinphotography

The Good News(cont.)

Traditional Clinical Examination

A: Asymmetry

B: Border irregularity

C: Colors

D: Diameter > 6 mm

E: Evolving lesions

Why Dermoscopy?

1. ABCD criteria are not always reliable

2. Common atypical looking, but benign lesions

3. Poor discrimination between pigmented melanocytic and pigmented non-melanocytic lesions

4. Unnecessary biopsies and surgeries

Dermatoscopy – Epiluminescence Microscopy

• Non-invasive, in-vivo microscopic technique using incident light, immersion oil, and low-to-medium power magnifying optics

• Helpful to differentiate pigmented melanocytic from pigmented non-melanocytic lesions

• Increases diagnostic accuracy of pigmented lesions

• Widely used in Europe• Becoming routine use in the USA

Principles of Dermoscopy

• New morphology appears with features that cannot be perceived by the naked eye

Dermoscopic Diagnosis of Melanocytic Tumors

1.High sensitivity 75-96%2.High specificity 79-98%

This improves with experience and far exceeds the rate by clinical examination alone

Recently Introduced Application of Dermoscopy on Equivocal Lesions

“Short Term Mole Monitoring”

1. Low concern lesions on clinical exam2. Newly developed lesions3. More of a concerns for the patient

3-4 months dermoscopic monitoring

Lesions are removed if further changes occur

. The diagnostic software of this computer analyzes the images by comparing to a large

data bank and provides a diagnostic score. The diagnostic score correlates with the biologic behavior of the lesion benign vs. malignant.

Based on the biopsy report, your Dermatologist will advise you if further

treatments are needed.

Skin Surface Microscopy

Image Analysis

StructuresColors

Patterns

Criteria

Clinico-pathologic correlation

Diagnosis

Algorithmic Approach of Pigmented Skin Lesions

Skin self-examination Dermoscopy

Total body skinphotography

The Patient - Physician Team Work

Periodic Exams with Multiple Techniques

The Importance of Total Body Photography

1. High-resolution digital overview photos of the entire skin surface

2. Standardized technique, lighting, distance, topography, etc.

3. Baseline record used for follow-up examination for comparison to detect new or changing lesions

4. One set for patient clinic records, another set for patient’s own records for self-exams

Marghoob te al. J Am Acad Dermatol 2003; 777-97.

Total Body Photography

Patients Who Benefit from TBP

1. Personal or family history of melanoma

2. “Atypical mole syndrome”

3. Multiple normal appearing nevi

4. Large congenital nevi

5. Genetic abnormalities (p16 gene)

6. High anxiety

Advantages of TBP

1. Help to identify new or changing lesions

2. Increase the efficiency of biopsying the right lesion

3. May save the life by earlier detection

Additional Advantages of TBP

1. Encouraging participation by involving self-screening

2. Reducing unnecessary biopsy rates for benign nevi

3. Reassuring patients that stable lesions are benign

Maximazing Positive Outcome

Goal

Better patient profiling

Improved identification techniques

Earliest possible diagnosis

Combination of Approaches

1. Optimize knowledge, resources, and techniques.

2. Select the high risk patient population

3. Combining techniques• Total body photography• Dermoscopy

4. Invest and develop new techniques

In vivo confocal scanning microscopy

Teledermatology

Melanomain situ

Margins !

Mobile Teledermatology

C.Ebner et al. J.Telemed. Telecare 2008

5. Collaborate with the full scale of multidisciplinary specialists:

– Dermatologists– Surgeons– Clinical oncologists– Pathologists, dermatopathologists– Psychiatrists– Researchers– Social Workers and– Survivors and their relatives

Combination of Approaches(cont.)

Beyond the Hard Core SciencePearls from Real Survivors

1. Emotional commitment to keep going despite ups and downs

2. Utilize all internal and external resources• Positive thinking• Goal setting, being creative• Find humor and playfulness• Share experiences and learn from others

3. Comply with Doctor’s instructions4. Appreciate life

• Living everyday in the fullest sense