Continuing medical education
Instruments and new technologies for the in vivo diagnosis of melanoma

https://doi.org/10.1016/S0190-9622(03)02470-8Get rights and content

Abstract

The principal objective of screening individuals at risk for melanoma is detection of cutaneous melanoma during the curable stages of its early evolution. Unaided visual inspection of the skin is often suboptimal at diagnosing melanoma. Improving the diagnostic accuracy for melanoma remains an area of active research. These research efforts have focused on both the detection of early melanoma and the in-depth evaluation of suspicious pigmented lesions for the presence or absence of melanoma. Numerous instruments are under investigation to determine their usefulness in imaging and ascertaining a correct in vivo diagnosis of melanoma. It is anticipated that some of these tools, alone or in combination, will improve our ability to differentiate, in vivo, melanoma from its simulators. Ultimately, these advances may prevent unnecessary biopsies (increased specificity) while increasing the sensitivity for diagnosing melanoma. This article reviews the current instruments and new technologies for the in vivo diagnosis of melanoma.

Learning objective

At the conclusion of this learning activity, participants should be acquainted with the instruments designed to facilitate the early detection of melanoma. They should also be familiar with the basic technology behind these instruments and should recognize the potential benefits and limitations inherent in each.

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.

References (160)

  • J. Malvehy et al.

    Follow-up of melanocytic skin lesions with digital total-body photography and digital dermoscopya two-step method

    Clin Dermatol

    (2002)
  • F.A. Bahmer et al.

    Terminology in surface microscopyconsensus meeting of the committee on analytical morphology of the Arbeitsgemeinschaft Dermatologische Forschung, Hamburg, Federal Republic of Germany, Nov 17, 1989

    J Am Acad Dermatol

    (1990)
  • A. Steiner et al.

    Statistical evaluation of epiluminescence microscopy criteria for melanocytic pigmented skin lesions

    J Am Acad Dermatol

    (1993)
  • M. Binder et al.

    Epiluminescence microscopy of small pigmented skin lesionsshort-term formal training improves diagnostic performance of dermatologists

    J Am Acad Dermatol

    (1997)
  • D. Massi et al.

    Histopathologic correlates of dermoscopic criteria

    Dermatol Clin

    (2001)
  • G. Pellacani et al.

    Comparison between morphological parameters in pigmented skin lesion images acquired by means of epiluminescence surface microscopy and polarized-light videomicroscopy

    Clin Dermatol

    (2002)
  • P. Carli et al.

    Preoperative assessment of melanoma thickness by ABCD score of dermatoscopy

    J Am Acad Dermatol

    (2000)
  • G. Argenziano et al.

    Clinical and dermatoscopic criteria for the preoperative evaluation of cutaneous melanoma thickness

    J Am Acad Dermatol

    (1999)
  • G. Argenziano et al.

    Epiluminescence microscopycriteria of cutaneous melanoma progression

    J Am Acad Dermatol

    (1997)
  • N. Cascinelli et al.

    A possible new tool for clinical diagnosis of melanomathe computer

    J Am Acad Dermatol

    (1987)
  • T. Schindewolf et al.

    Evaluation of different image acquisition techniques for a computer vision system in the diagnosis of malignant melanoma

    J Am Acad Dermatol

    (1994)
  • A. Green et al.

    Computer image analysis in the diagnosis of melanoma

    J Am Acad Dermatol

    (1994)
  • S. Seidenari et al.

    Digital videomicroscopy improves diagnostic accuracy for melanoma

    J Am Acad Dermatol

    (1998)
  • W. Stolz et al.

    Improvement of monitoring of melanocytic skin lesions with the use of a computerized acquisition and surveillance unit with a skin surface microscopic television camera

    J Am Acad Dermatol

    (1996)
  • P. Rubegni et al.

    Digital dermoscopy analysis and artificial neural network for the differentiation of clinically atypical pigmented skin lesionsa retrospective study

    J Invest Dermatol

    (2002)
  • W.G. Baxt

    Application of artificial neural networks to clinical medicine

    Lancet

    (1995)
  • M. Elbaum et al.

    Automatic differentiation of melanoma from melanocytic nevi with multispectral digital dermoscopya feasibility study

    J Am Acad Dermatol

    (2001)
  • M. Elbaum

    Computer-aided melanoma diagnosis

    Dermatol Clin

    (2002)
  • J.M. Elwood et al.

    The first signs and symptoms of melanomaa population-based study

    Pigment Cell Res

    (1988)
  • R.J. Friedman et al.

    Early detection of malignant melanomathe role of physician examination and self-examination of the skin

    CA Cancer J Clin

    (1985)
  • A.J. Sober et al.

    Early recognition of cutaneous melanoma

    JAMA

    (1979)
  • Rigel DS, Carucci JA. Malignant melanoma: prevention, early detection, and treatment in the 21st century. CA Cancer J...
  • A.A. Marghoob et al.

    The ABCDs of melanomawhy change?

    J Am Acad Dermatol

    (1995)
  • T.W. McGovern et al.

    Clinical predictors of malignant pigmented lesionsa comparison of the Glasgow seven-point checklist and the American Cancer Society's ABCDs of pigmented lesions

    J Dermatol Surg Oncol

    (1992)
  • M. Keefe et al.

    A study of the value of the seven-point checklist in distinguishing benign pigmented lesions from melanoma

    Clin Exp Dermatol

    (1990)
  • J.E. Osborne et al.

    False negative clinical diagnoses of malignant melanoma

    Br J Dermatol

    (1999)
  • J.D. Whited et al.

    Does this patient have a mole or a melanoma?

    JAMA

    (1998)
  • C.M. Grin et al.

    Accuracy in the clinical diagnosis of malignant melanoma

    Arch Dermatol

    (1990)
  • C.A. Morton et al.

    Clinical accuracy of the diagnosis of cutaneous malignant melanoma

    Br J Dermatol

    (1998)
  • H.K. Koh et al.

    Screening for melanoma/skin cancertheoretic and practical considerations

    J Am Acad Dermatol

    (1989)
  • A.W. Kopf et al.

    Diagnostic accuracy in malignant melanoma

    Arch Dermatol

    (1975)
  • Wolf IH, Smolle J, Soyer HP, et al. Sensitivity in the clinical diagnosis of malignant melanoma. Melanoma Res...
  • R.K. Curley et al.

    Accuracy in clinically evaluating pigmented lesions

    BMJ

    (1989)
  • W.K. Andersen et al.

    ′Melanoma? It can't be melanoma!' A subset of melanomas that defies clinical recognition

    JAMA

    (1991)
  • I.H. Wolf et al.

    Dermatoscopic features of dysplastic nevi in melanoma and non-melanoma patients

    Melanoma Res

    (2001)
  • A.C. Halpern

    The use of whole body photography in a pigmented lesion clinic

    Dermatol Surg

    (2000)
  • K.S. Nehal et al.

    Use of and beliefs about baseline photography in the management of patients with pigmented lesionsa survey of dermatology residency programs in the United States

    Melanoma Res

    (2002)
  • P.F. Hanrahan et al.

    Examination of the ability of people to identify early changes of melanoma in computer-altered pigmented skin lesions

    Arch Dermatol

    (1997)
  • S.W. Menzies et al.

    Frequency and morphologic characteristics of invasive melanoma lacking specific surface microscopic features

    Arch Dermatol

    (1996)
  • M.E. Ming et al.

    Microscopic features of histopathologically misdiagnosed melanoma

    Melanoma Res

    (2001)
  • Cited by (0)

    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.

    View full text