Continuing medical educationInstruments and new technologies for the in vivo diagnosis of melanoma☆
Section snippets
Magnifyng lens, Wood's light, and UV photography
The simple use of a magnifying glass can often assist the clinician in differentiating and correctly diagnosing many pigmented lesions (Table IA, Table IB, Table IC). Magnification can, for example, allow for easy visualization of comedo-like openings in seborrheic keratoses and telangiectasias in pigmented basal cell carcinomas, thus, helping to exclude melanoma from the differential diagnosis.
The emission from a Wood's lamp, with a wavelength near the UV spectrum (360 nm), is strongly
Baseline clinical photography
Physicians frequently encounter situations where the clinical diagnosis of a pigmented lesion is in question. The presence of baseline photographs of the lesion can often make the decision of whether or not to biopsy an easy one.34, 45 Most pigmented lesions that are stable and without change can be followed up periodically. However, those lesions that are new or have significantly changed may need to be biopsied. Most dermatologists believe that baseline photography is useful in the follow-up
Dermoscopy
Dermoscopy (epiluminescence microscopy, Dermatoscopy, skin surface microscopy) is a noninvasive technique that uses a handheld instrument called a dermoscope. The dermoscope is equipped with a transilluminating light source and standard magnifying optics. After the application of a liquid interface (usually oil, water, or alcohol) to the surface of the skin, the dermoscope lens is immersed into the fluid covering the lesion. The liquid interface decreases light reflection, refraction, and
Image analysis and computer-assisted diagnosis
Advances made in computer technology, digital imaging, and computer programming have been applied by researchers to explore their potential uses in the evaluation of pigmented cutaneous lesions.72, 73 Numerous computer programs have been created to objectively document the clinical features of digitized pigmented lesion images. Most of these systems rely on sophisticated programs for lesion segmentation, which determines the boundary separating the lesion from the surrounding normal skin.74
Multispectral imaging and automated diagnosis
The knowledge that light of different wavelengths penetrates the skin to different depths led investigators to evaluate pigmented lesions under specific wavelengths of light from the infrared to near UV range (Table VII). 94, 95 Sequences of images taken at different wavelengths of light are called multispectral images. Currently there are 2 systems, spectrophotometric intracutaneous analysis (SIA) scope and MelaFind, which use multispectral dermoscopic images as the inputs for subsequent
CSLM
CSLM is a noninvasive imaging system that allows for the in vivo examination of the epidermis and papillary dermis at a resolution approaching histologic detail (Virascope, Lucid, Inc, USA, and Optiscan, Optiscan Pty Ltd, Australia).101, 102, 103, 104, 105, 106 CSLM works by tightly focusing a low-power laser beam (visible or near infrared wavelength) on a specific point in the skin, and detecting only the light reflected from that focal point through a pinhole-sized spatial filter (Fig 10).
Ultrasound
In recent years high-frequency ultrasound has attained application in clinical dermatology, with European countries using this technique for standard diagnostic purposes.116 The ultrasound images are created due to the different acoustic properties of tissues. High-frequency sound impulses are transmitted into the skin and then reflected, refracted, or inflected when a tissue interface with different acoustic impedance is encountered.117 The amplitude of the intensity of the reflections at
Optical coherence tomography
Optical coherence tomography (OCT) is analogous to ultrasound B imaging, except that it uses light rather than sound waves.142 It is described as an intermediate imaging device between ultrasound and CSLM.143 The OCT technique is based on the principle of Michelson interferometry.144 A pulse of near infrared, low-coherence light is split such that half the beam is sent to the specimen and half to a scanning reference mirror. The light to the specimen is focused on the papillary skin layers,
Magnetic resonance imaging
Magnetic resonance imaging (MRI) has also been used experimentally in the examination of pigmented skin lesions (Fig 16). 149, 150 The application of MRI to dermatology has become practical with the use of specialized surface coils that allow higher resolution imaging than standard MRI coils.151 At this point in time, however, the technology remains experimental with no specific dermatologic applications established. The principle of MRI involves the absorption and re-emission of radiowaves
Conclusion
New techniques, instruments, and technologies are needed to help diagnose early melanoma. Current available instruments to assist the early diagnosis of melanoma include photography, magnifying lens, Wood's light, dermoscopy, CSLM, ultrasound, MRI, OCT, and multispectral imaging. It is important to emphasize that pigmented lesions need to be evaluated in the context of a patient's entire skin examination. Only those lesions considered to be different160 or suspicious can be subjected to further
Acknowledgements
addendum: Images of the various equipment used for the in vivo diagnosis of melanoma are available on our Web site, http://www.dermoncology.com.
We thank Daphne Demas for her technical assistance with the preparation of prints for this article. Thanks to Milind Rajadhyaksha at Massachusetts General Hospital, Boston, for providing us with an unpublished confocal reflectance image.
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Cited by (0)
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Supported by the Ronald O. Perelman Department of Dermatology, New York University School of Medicine; Joseph M. Hazen Foundation; Mary and Emanuel Rosenthal Foundation; Kaplan Comprehensive Cancer Center (Cancer Center Support Core Grant No. 5P30-CA-16087); Blair O. Rogers Medical Research Fund; the Rahr Family Foundation; and Stavros S. Niarchos Foundation Fund of The Skin Cancer Foundation.
Disclosure: Dr Kopf is involved with the development of the Melafind equipment with Electro-Optical Sciences, Inc (Irvington, NY), but has not received any personal remuneration from this work. Dr Swindle had a research consultation role with Optiscan Pty Ltd (Australia) within the last 5 years.