Download - 1. Zero to Hero Pacific NW€¦ · Derma Medical (MoleMax, DermLite) EquipMed(MoleMax, DermLite) Canfield Scientific Inc. Hotspots Hawaii Wilcox Hospital Kauai Hawaii International

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Dermatoscopy Zero to HeroChaos & Clues

Prediction without Pigment

Cliff Rosendahl MBBS PhD FSCCA

Associate Professor School of Medicine The University of Queensland Australia

Brisbane

Darwin

Sydney

Perth

Brisbane

Darwin

Sydney

Perth

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…visiting the iniquity of the fathers upon the children unto the third and fourth generation…Exodus chapter 20 verse 5

Lake Chelan 48 degrees North Brisbane 27 degrees South

…visiting the iniquity of the fathers upon the children unto the third and fourth generation…Exodus chapter 20 verse 5

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•Dermatology

•Dermatologists

(1920)

Dermatologists

•Dermatoscope

•Dermatoscopy

Conflict of interest…

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156,000 Chaos and Clues posters to every hospital, doctor and dentist in Poland

Conflicts of Interest — Presenter(honorarium/expenses)

Skin Cancer College AustralasiaHealthcert InternationalLeo Pharma P/L3Gen Inc.University of California (Davis campus)Dermatology Associates of Wisconsin (Kohler, Wisconsin USA)Sonic Health Care Sullivan Nicolaides PathologyDouglass Hanly Moir PathologyCosmetic Surgery Forum (Las Vegas, USA)Derma Medical (MoleMax, DermLite)EquipMed (MoleMax, DermLite)Canfield Scientific Inc.Hotspots HawaiiWilcox Hospital Kauai HawaiiInternational Dermoscopy SocietyMelanoma Patients Australia

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What is dermatoscopy?

• a non‐invasive diagnostic technique for skin lesions

• a low powered microscope designed for visualisation of pigmentation and vessels by p g yreducing the amount of light reflected off the skin surface by either• Contact fluid immersion• polarising filters

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Clinical examination looks at lesions in the horizontal plane

In contrast, conventional microscopy looks at lesions in the vertical plane

Because melanin appears as different colours at different depths in the skin dermatoscopy provides information in both the horizontal and vertical planes. It provides a 3-dimensional view

Atlas of DermoscopyMarghoob Braun Kopf. Page 11

Why use dermatoscopy?

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Routine examination

Dermlite Pro IIHR Heine Delta 20

Photography‐most images in this presentation

Dermlite Fluid

DermLite DL3

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Polarised vs Non‐Polarised

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Image courtesy Yoon Cohen

Image courtesy Yoon Cohen

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4‐dot clods

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Chaos and Clues

• ALL pigmented lesions

• Detects malignancy ANY type

• No need to decide whethermelanocytic

• Can be applied at examination speed

• Efficacy similar to the other algorithms

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Understanding colours in Dermatoscopy

The Tyndall Effect

Why is the sky blue?

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The chaos factorThe chaos factor…

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Natural laws favour symmetry

• Gravity

• Electrical and magnetic fields

• Surface tension

• Biologic Feed‐back mechanisms that evolved

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Pattern + Colours + Clues = Diagnosis

Revised Pattern Analysis

Pattern + Colours + Clues(9) = Malignancy

Chaos & Clues

Pattern + Colours + Clues(9) = Malignancy

Chaos & Clues

Chaos + Clues(9) = Malignancy

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CHAOS

CHAOS

Asymmetry of Structure and/or colour

CHAOS: Structure; Colour; Border

• 1987 – Pehamberger – Classic Pattern Analysis

• 1989 – First hand‐held dermatoscope – consensus meeting –metaphoric terminology

• 1994 – Stolz – ABCD rule

• 1996 – Menzies’ method

• 1998 – Argenziano – 7 point checklist

Acknowledging prior work…

• 1998 The Ugly Duckling Sign

• 1998 The Little Red Riding Hood sign

• 2000 – Soyer/Argenziano – 3 point checklist

• 2007 – CASH (colour, architecture, symmetry, and homogeneity) version of pattern Analysis

• 2007 The beauty and the beast sign

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Jenny Multiple

Pigmented or non‐pigmented?

What structures/patterns?

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Lines

Pseudopods

Dots

Clods

Circles

Lines

Pseudopods

Reticular

Branched

ll l

Dots

Clods

Circles parallel

Radial

Curved

Structureless

Lines

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CHAOS?

Chaos No chaos Chaos No chaos

Judge on pattern and colour, not on outlineJudge on pattern and colour, not on outline

CHAOS?

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CLUES

GET BLACK LOLLIPOPS

Grey or blue structures

Eccentric structureless area

Thick lines reticular

Black dots or clods peripheral

Lines radial or pseudopods , segmental

Lines white

Lines parallel ridges (palms or soles) or chaotic (nails)

Polymorphous vessels

Polygons

Bill

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Pattern breaker?

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CHAOS?

CHAOS?CHAOS: Structure; Colour; Border

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Melanoma in‐situ

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Photographs Cliff Rosendahl

Jim

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Melanocytic or non‐melanocytic?

CHAOS?

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Pigmented SCC in‐situ/Solar lentigo collision

BRIAN

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Melanoma invasive

MelanoticNot melanocytic

AmelanoticMelanocytic

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MelanoticNot melanocytic

AmelanoticMelanocytic

The so‐called MELANOCYTIC criteria are not melanocytic at all. They are MELANOTIC criteria

Mary

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CHAOS?


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Melanoma insitu

www.derm101.com

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Julius


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SCC arising in a scar

Not circles

Pattern of lines reticular interrupted by follicular openings in a solar lentigo Pattern of circles in an in-situ

melanoma on the ear lobe

Circles

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Jenny Multiple

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CHAOS?

Florence

Pattern breaker?

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CHAOS?


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Melanoma in‐situ

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Harry

Images courtesy Moayad Al Kaptan

Pattern breaker?

Images courtesy Moayad Al Kaptan


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CHAOS?


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Trichilemmoma/BCC

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Photographs Cliff Rosendahl

Jenny Multiple

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CHAOS?


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Melanoma in‐situ

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Hazel


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CHAOS?

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CHAOS: Structure; Colour; Border

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BCC

Harry

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CHAOS?

Not excised

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Photograph Alan Cameron Photograph Alan Cameron

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CHAOS?

Eccrine duct openings in centre of ridge

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Melanoma in‐situ

Image courtesy Richard Williamson

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CHAOS?


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Melanoma invasive arising in a nevus

Sir

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Pattern breaker?

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CHAOS?

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4433

Rete ridges with various width and melanin density produce lines of varying width, interval and colour

1 Poster 1 smart kid

1 rare in-situ melanoma

+ =

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Eddie

Pattern breaker?


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CHAOS?


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Melanoma invasive

Joe

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Pattern breaker?

CHAOS?


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Melanoma in‐situ

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Polygons

Polygons

Polygons

A geometric polygonal shape complete or incomplete, bounded by straight lines, or by a straight pigment interface, meeting at angles and larger than the holes caused by individual follicles and larger by far than the holes bounded by reticular lines.

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Elaine

Pattern breaker?

CHAOS?

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Melanoma nodular Breslow 0.9

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Bruce


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CHAOS?

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Melanoma invasive

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Chaos and Clues

Photograph Alan Cameron

Photograph Alan Cameron

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Excluding seborrhoeic keratoses

• Multiple orange or yellow clods

• Multiple white clods

• Thick curved lines

• Well demarcated border

• Multiple grouped similar lesionsp g p

Malignant conditions can have individual criteria

Weigh the clues to arrive at a diagnosis

If in doubt at all ‐ BIOPSY

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CHAOS?

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CHAOS?


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Melanoma invasive

Photograph Cliff Rosendahl

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Do you need dermatoscopy?




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Clues to Melanoma

RR PPV% NPV% Sensitivity% Specificity%

Pigmented circles 3.7 25 95.93 70.83 76.39

G i l 4 6 26 5 94 2 54 2 83 3Grey circles 4.6 26.5 94.2 54.2 83.3

Incomplete circles 3.0 18.4 93.9 58.3 71.3

Grey colour 8.9 13.3 98.5 95.8 30.6

dot vessels 3.5 33.3 90.6 8.3 98.1

95.8% of flat facial melanomas have grey colour but it is only 30.6% specific.

Pigmented circles are not as common (sensitivity 70.83% ) but they are 76.39% specific for melanoma

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Hi Cliff,…This guy was worried about a seb K on his arm. I advised a full skin check and found thisfull skin check and found this …

All the best,Finbar McGrady

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Pattern breaker?

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“LOST MY MELANOMA VIRGINITY!”

Hi Cliff,…Its a bit weird I'm so excited about this but I found my first melanoma! Clark Level 2 Breslow 0 38mmmelanoma! Clark Level 2, Breslow 0.38mm.…

All the best,Finbar McGrady

Thank you!

References

1. Rosendahl C, Cameron A, McColl I, Wilkinson D. Dermatoscopy in routine practice “Chaos and Clues.”Aust Fam Physician. 2012 Jul;41(7):482–7.

2. Kittler H, Rosendahl C, Cameron A, Tschandl P. Dermatoscopy www Facultas, Austria

3. Canfield Scientific Inc4. Cohen YK, Elpern DJ, Wolpowitz D, Rosendahl C. Glowing in the dark: casereport of a clue‐poor melanoma unmasked by polarized dermatoscopy. DermatolPract Concept. 2014;4(1):14. http://dx.doi.org/10.5826/dpc.0401a14

5. Tschandl P, Rosendahl C, Kittler H. Dermatoscopy of flat pigmented facial lesions. J Eur Acad Dermatol Venereol. 2014 Mar 24; ;

6. Ashfaq A. Marghoob, Ralph Braun, Proposal for a Revised 2‐Step Algorithm for theClassification of Lesions of the Skin Using Dermoscopy ARCH DERMATOL/VOL 146 (NO. 4), APR 2010

7. Tschandl P, Rosendahl C, Kittler H. Accuracy of the first step of the dermatoscopic2‐step algorithm for pigmented skin lesions. Dermatol Pract Conc. 2012;2(3):8.http://dx.doi.org/10.5826/dpc.0203a08.

8. Kittler H. Dermatoscopy: Introduction of a new algorithmic method based onpattern analysis for diagnosis of pigmented skin lesions. Dermatopathology: Practical & Conceptual. 2007;13(1):3. Available at: http://www.derm101.com.

9. Weismann K, Lorentzen HF. Dermoscopic color perspective. Arch Dermatol2006;142:1250.

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10. Rosendahl C, Tschandl P, Cameron A, Kittler H. Diagnostic accuracy of dermatoscopy for melanocytic and nonmelanocytic pigmented lesions. J. Am.Acad. Dermatol. 2011 Jun;64(6):1068–73.

11. Tschandl P, Cameron A, Rosendahl C, Kittler H. Analytical comparison of the 3‐point,7‐point, ABCD, Menzies and Chaos and Clues dermatoscopic algorithms. Presented at the 2nd International Congress of the International Dermoscopy Society, Barcelona, Spain, November 2009

12. Marghoob AA, Korzenko AJ, Changchien L, Scope A, Braun RP, Rabinovitz H. The beauty and the beast sign in dermoscopy. Dermatol Surg. 2007 Nov;33(11):1388–91.

13. Morris AD, Gee BC, Millard LG. Geometric cutaneous melanoma: a helpful clinical sign of malignancy? Dermatol Surg. 2003 Aug;29(8):827–8; discussion 829.

14 R d hl C C A B li k A Willi R Ki l H D f14. Rosendahl C, Cameron A, Bulinska A, Williamson R, Kittler H. Dermatoscopy of a minute melanoma. Australas J Dermatol. 2011 Feb;52(1):76–8.

15. Rosendahl C, Hishon M, Cameron A, Barksdale S, Weedon D, Kittler H. Nodular melanoma: five consecutive cases in a general practice with polarized and non‐polarized dermatoscopy and dermatopathology. Dermatol Pract Concept. 2014;4(2):15.

16. Rosendahl C, Cameron A, Tschandl P, Williamson R, Kittler H. The Cause of Dermatoscopic Grey Circles in Non‐Invasive Melanomas: A Hypothesis Supportedby Histopathological Correlation. ‘Best Poster award’ received. www.greycircles.blogspot.com

17. Li W‐Q, Qureshi AA, Robinson KC, Han J. Sildenafil Use and Increased Risk of Incident Melanoma in US Men: A Prospective Cohort Study. JAMA Intern Med. 2014 Jun 1;174(6):964–70.

18. Kittler H, Tschandl P. Dysplastic nevus: why this term should be abandoned indermatoscopy. Dermatol Clin. 2013 Oct;31(4):579–588, viii.

19. Tsao H, Bevona C, Goggins W, Quinn T. The transformation rate of moles (melanocytic nevi) into cutaneous melanoma: a population‐based estimate. Arch Dermatol. 2003 Mar;139(3):282–8.

20. Kittler H, Reidl E, Rosendahl C, Cameron A . “Dermatoscopy of unpigmentedlesions of the skin: a new classification of vessel morphology based on patternanalysis,” Dermatopathology: Practical & Conceptual 14, no. 4 (December 2008)2008).

21. Rosendahl C, Cameron A, Tschandl P, Bulinska A, Zalaudek I, Kittler H. Prediction without Pigment: a decision algorithm for non‐pigmented skin malignancy. Dermatol Pract Concept. 2014;4(1):9. http://dx.doi.org/10.5826/dpc.0401a09

22. Rosendahl C, Cameron A, Wilkinson D, Belt P, Williamson R, Weedon D.Nail matrix melanoma: consecutive cases in a general practice. Dermatol PractConc. 2012;2(2):13. http://dx.doi.org/10.5826/dpc.0202a13

23. Keir J. Dermatoscopic features of cutaneous non‐facial and non‐acral lentiginous growth pattern melanomas. Dermatol Pract Concept. 2014;4(1):13. http://dx.doi.org/10.5826/dpc.0401a13

24. Rosendahl C, McGrady F. Patients dressed to kill. Medical Observer, St Leonards, NSW, Australia. 2013 July 26; page 28