S.W. Dusza

Detection of basal cell carcinomas in Mohs excisions with fluorescence confocal mosaicing microscopy

Background  High‐resolution real‐time imaging of human skin is possible with a confocal microscope either in vivo or in freshly excised tissue ex vivo. Nuclear and cellular morphology is observed in thin optical sections, similar to that in conventional histology. Contrast agents such as acridine orange in fluorescence and acetic acid in reflectance have been used in ex vivo imaging to enhance nuclear contrast.

Dermoscopic patterns of naevi in fifth grade children of the Framingham school system.

Background  Childhood is a critical period for naevogenesis.

Assessment of sunscreen knowledge: a pilot survey

Background  Topical sunscreens are designed to block and absorb UV radiation from the sun and have the potential to decrease the risk of skin cancer and delay the photoaging. Many studies have examined the behavior patterns of the public on sunscreen use, but little is known regarding the level of knowledge the public has regarding sunscreen.

Genetic factors associated with naevus count and dermoscopic patterns: preliminary results from the Study of Nevi in Children (SONIC).

Melanocytic naevi are an important risk factor for melanoma. Naevi with distinct dermoscopic patterns can differ in size, distribution and host pigmentation characteristics.

Melanocytic naevi with globular and reticular dermoscopic patterns display distinct BRAF V600E expression profiles and histopathological patterns

BRAF (v‐raf murine sarcoma viral oncogene homologue B) V600E mutations have been detected with high frequency in melanocytic naevi. Few studies have stratified analyses by naevus dermoscopic pattern.

Cross‐sectional analysis of the dermoscopic patterns and structures of melanocytic naevi on the back and legs of adolescents

Junctional (flat) naevi predominate on the extremities, whereas dermal (raised) naevi are found primarily on the head, neck and trunk. Few studies have investigated the anatomical site prevalence of melanocytic naevi categorized using dermoscopy.

Clinical and dermoscopic characteristics of new naevi in adults: results from a cohort study.

Naevogenesis is a process known to occur throughout life. To date, investigators have made conclusions about new naevi in adults based on results of cross‐sectional studies.

Variation in dermoscopic features of basal cell carcinoma as a function of anatomical location and pigmentation status

DEAR EDITOR, Detecting basal cell carcinomas (BCCs) early and at relatively small sizes may expand therapeutic choices and enable less invasive treatment options. To this end, dermoscopy is a useful tool to diagnose BCC at early stages with high sensitivity and specificity. Superficial BCCs have been shown to be independently associated with location on the trunk and extremities and nodular BCCs have been independently associated with a head/neck location. Few studies have evaluated dermoscopic variation in BCC morphology as a function of anatomical location and pigmentation status. Herein, we evaluate BCC dermoscopic morphology based on pigmentation status and anatomical location. We conducted a retrospective analysis of patient demographics and dermoscopic and clinical features of consecutive histopathologically proven BCCs that had been biopsied between 1 December 2007 and 1 March 2014 at the Pigmented Lesion Clinic of Skin and Cancer Associates, Plantation, FL, U.S.A. Collision and recurrent tumours, and cases with poor image quality were excluded. Clinical and dermoscopic images were taken in vivo with a Nikon Coolpix 4500 camera Nikon USA, Inc., Melville, NY, U.S.A. and DermLite II Pro HR and DermLite II Fluid dermoscopes, 3Gen Inc., San Juan Capistrano, CA, U.S.A. at 910 magnification. Dermoscopic images were routinely taken via nonpolarized and polarized contact and noncontact dermoscopy. Each lesion was classified by anatomical site as: head/neck, upper extremities (UE), trunk, and lower extremities (LE). Lesions were assessed for pigmentation and for the presence/absence of dermoscopic features. Of 479 consecutively biopsied BCCs evaluated, 392 histopathologically proven BCCs on 348 unique patients were included in the study (87 BCCs were excluded because of poor image quality). Tumours were on the head/neck for 169 (43%) lesions, trunk for 129 (33%), LE for 54 (14%) and UE for 40 (10%). The average patient age was 64 9 years (range 50 0–79 8). Pigmented lesions varied significantly across anatomical sites, with the highest frequency on the UEs (65 0%) and lowest frequency on the head/neck (49 1%). Compared with other anatomical sites (head/neck, UE and trunk) combined, BCCs on the LEs had a higher frequency of polymorphous vessels (74% vs. 44%), thin serpentine vessels (81% vs. 63%), shiny white blotches (85% vs. 46%), long white strands (76% vs. 45%), erythema (87% vs. 59%) and erosions/ulcers (69% vs. 35%) (P ≤ 0 01 for all comparisons). BCCs on the LE had the lowest frequency of arborizing vessels (24% vs. 78%) (P ≤ 0 0001) when compared with all anatomical sites. Overall, while 264 lesions contained arborizing vessels, 84 contained additional vessel morphologies resulting in the polymorphous attribute. Clinically, 35 2% BCCs were pigmented, and 57 7% were pigmented under dermoscopy. Compared with pigmented BCCs, nonpigmented BCCs were more likely to have arborizing vessels (77% vs. 59%), erythema (57% vs. 46%), shiny white blotches (48% vs. 34%) and long white strands (47% vs. 33%) (P < 0 05 for all) (Table 1). BCCs on the LE have been associated with female sex, a younger age at diagnosis, and a superficial histopathological subtype. While studies examined dermoscopic morphology of BCC of the head/neck vs. truncal location, data are limited on dermoscopic features of BCCs on the LE. In corroboration with Suppa et al., we found that BCCs of the head/neck frequently presented with arborizing vessels and BCCs on the trunk frequently presented with leaf-like structures, concentric structures, erosions/ulcers and polymorphous vessels. It is important to note that our analysis included the full spectrum of BCC histopathological subtypes (including infiltrative and morphoeiform). In addition, the present study evaluated all BCCs with nonpolarized and polarized images. By including nonpolarized and polarized images for every lesion, we characterized the full spectrum of dermoscopic features in BCC. The dermoscopic picture of BCCs on the LEs described in this study is strikingly different from those on the head/neck. Our study has established that shiny white streaks (SWS), polymorphous vessels and ulceration/erosions should raise suspicion for BCC. This is an important finding because polymorphous vessels and ulceration are features highly associated with melanoma. Our experience and the findings show that the combination of dermoscopic features of polymorphous vessels, ulcerations/erosions and SWS, identified via polarized light, can tilt the differential towards BCC, especially in LE lesions. In the present study, the BCC subtype was predominantly nodular, then infiltrative, superficial and other. The subtype distribution reflects an older population with sun-damaged skin presenting to the study clinic. Our sample size precluded us from meaningfully exploring the relationship between BCC subtype and anatomical location. Other limitations include the use of images from a single practice and a retrospective study design. Despite these limitations, we demonstrate that BCCs

A Clinical Aid for Detecting Skin Cancer: The Triage Amalgamated Dermoscopic Algorithm (TADA)

Purpose: Family physicians (FPs) frequently evaluate skin lesions but may not have the necessary training to accurately and confidently identify lesions that require skin biopsy or specialist referral. We evaluated the diagnostic performance of a new, simplified dermoscopy algorithm for skin cancer detection. Methods: In this cross-sectional, observation study, attendees of a dermoscopy course evaluated 50 polarized dermoscopy images of skin lesions (27 malignant and 23 benign) using the Triage Amalgamated Dermoscopic Algorithm (TADA). The dermoscopic criteria of TADA include architectural disorder (ie, disorganized or asymmetric distribution of colors and/or structures), starburst pattern, blue-black or gray color, white structures, negative network, ulcer, and vessels. The study occurred after 1 day of basic dermoscopy training. Clinical information related to palpation (ie, firm, dimpling) was provided when relevant. Results: Of 200 course attendees, 120 (60%) participated in the study. Participants included 64 (53.3%) dermatologists and 41 (34.2%) primary care physicians, 19 (46.3%) of whom were FPs. Fifty-two (43%) individuals had no previous dermoscopy training. Overall, the sensitivity and specificity of TADA for malignant skin lesions was 94.8% and 72.3%, respectively. Previous dermoscopy training and years of dermoscopy experience were not associated with diagnostic sensitivity (P = .13 and P = .05, respectively) or specificity (P = .36 and P = .21, respectively). Specialty type was not associated with sensitivity (P = .37) but dermatologists had a higher specificity than nondermatologists (79% v. 72%, P = .008). Conclusions: After basic instruction, TADA may be a useful dermoscopy algorithm for FPs who examine skin lesions as it has a high sensitivity for detecting skin cancer.

Towards three‐dimensional temporal monitoring of naevi: a comparison of methodologies for assessing longitudinal changes in skin surface area around naevi

DEAR EDITOR, Although change in a skin lesion is a sensitive clue to the diagnosis of melanoma, all skin lesions grow at some point during their lifespan. Few studies have assessed how skin lesions change in size relative to the body. Rhodes et al. estimated the relative growth of congenital naevi in infants by comparing changes in naevus surface area (referred to hereafter simply as ‘area’) with regional body area changes calculated using height and weight data and adjusted for age. They found disproportionate growth in the first 6 months followed by proportionate growth thereafter. As body sites change at different rates and are influenced by age, sex and environmental factors, it is unclear whether this approach is uniformly valid or whether other methodologies might be more applicable. Until recently, measuring change in skin area was not readily feasible (i.e. paper cast or palm techniques), but the advent of three-dimensional (3D) stereophotogrammetrybased imaging in dermatology clinics now offers an opportunity for precise study of perilesional area changes. Here we compared 3D-imaging-observed area changes with those calculated from two-dimensional (2D) imaging or inferred from height and weight data. This is part of the Study of Nevi in Children (SONIC), which to our knowledge is the first to follow naevi longitudinally using 3D imaging. SONIC was approved by the Harvard University Institutional Review Board and adhered to the guidelines of the Declaration of Helsinki. Participant accrual and data collection have been reported previously. Relevantly to this study, participants had 180° anterior and posterior 3D body images and 2D overview images of the back and legs captured at baseline (age ~14 years) and 3 years later using standardized poses, along with height and weight measurements. Three-dimensional images were obtained using a customized Vectra Body System (Canfield Scientific, Inc., Fairfield, NJ, U.S.A.), which had a stereocapture array of twelve 21-megapixel digital single-lens reflex cameras configured to meet the study capture field, and photographic texture-resolution requirements. The calibrated dimensional imaging system collected each image in under 4 ms to produce a 3D model. Vectra systems have been validated for accuracy and are in clinical use. Digital 2D images were obtained using a Phase One P25 Camera Back, Hasselblad 503w Camera System, 2kWatt Studio Flash System (Canfield Scientific, Inc.). The area around naevi (or ‘perilesional area’) was measured on 3D and 2D images using four neighbouring landmark naevi (‘anchors’) that surrounded the naevus. These ‘anchors’ had to be clearly visible at both time points (Fig. 1). When four neighbouring landmark naevi could not be identified, the index naevus was used as the fourth landmark. In a pilot experiment using 3D images of a single participant taken 15 min apart, we explored the precision and repeatability of the 3D Vectra body system and use of perilesional area measurements for 10 back naevi. We found a mean coefficient of variability of 1 04%, supporting the reproducibility of this approach. To explore further the area change measurements, we calculated the 3D and 2D regional area, defined as the area of the upper back, lower back or lower leg (Fig. 2), and the total body surface area (TBSA) (TBSA = xHM; where x, y and z are constants equalling 0 02667, 0 38217 and 0 53937, respectively; H is height and M is mass). A convenience sample of 93 naevi from 65 participants (33 male) was chosen from the upper back (n = 29), lower back (n = 21), upper leg (n = 22) and lower leg (n = 21). Feasibility of naevus perilesional area measurements was required for inclusion, and we overselected naevi on the lower back and legs to include similar proportions by anatomical site (Appendix S1 and Tables S1–3; see Supporting Information). The mean 3D perilesional area increased after 3 years by 16 1% (95% confidence interval 13 0–19 3). There was nearly perfect interand intraobserver reliability (intraclass correlation coefficient of 0 99 for both measures). To assess the accuracy of the 3D imaging system and measurement tool, coloured adhesive dots that were originally placed adjacent to naevi during photography sessions for tracking purposes were randomly selected from 10 participants, and their diameters were measured at both time points. The mean diameter was 12 83 0 13 mm, comparable with the manufacturer’s reported specification of 12 70 mm. Nonvisible landmark naevi located on curved surfaces precluded 2D perilesional area measurements in 29 cases (31%). For the 64 naevi with both 2D and 3D perilesional area measurements, 3D perilesional area measurements were consistently greater than 2D (baseline 69 0 vs. 59 4 cm; follow-up 87 5 vs. 72 6 cm; P < 0 001), but there was no difference in the mean change between 3D and 2D perilesional area (17 0% vs. 17 6%, P = 0 8).