Melanoma surveillance by multimode, hyperspectral dermoscopy and self-imaging using smartphone in high-risk patients

Author(s): Vasefi, Fartash; MacKinnon, Nicholas; Booth, Nicholas; Durkin, Anthony J; Kelly, Kristen; FarKas, Daniel

Melanoma in situ with inconspicuous clinical and dermoscopic features: A case report illustrating the usefulness of reflectance confocal microscopy Viktoryia Kazlouskaya, MD, SUNY Downstate; Juliya Fisher, MD, SUNY Downstate; Usha Alapati, MD, SUNY Downstate; Orit Markowitz, MD, SUNY Downstate; Katherine Siamas, MD, SUNY Downstate Today, dermatologists are diagnosing early melanoma more often, and given the numerous new tools at our disposal we have been able to even further facilitate the diagnostic process. Dermoscopy has become an important instrument for dermatologists and its use has led to a higher diagnostic rate. Dermoscopy and a clinical impression, together, are sufficient in most cases to diagnose a melanoma, but there are still cases when the diagnosis cannot be made with certainty. Although biopsy is the criterion standard in confirming the diagnosis, when lesions are located on the face, it may undesirable to the patient to have the procedure, without additional confirmation. Reflectance confocal microscopy (RCM) is a relatively new modality that is being implemented as a supplemental tool for the diagnosis of both nonmelanoma skin cancer and melanoma. Several RCM features (pagetoid spread, dendritic melanocytes, disarray of the epidermis, and bright granular particles) may assist in strengthening the suspicion for melanoma and provide additional information to proceed with a. Recent studies have shown that RCM has a high specificity and sensitivity in the evaluation of equivocal facial lesions. Herein, we present a case of a 71-year-old man with a pigmented lesion on the face, demonstrating equivocal clinical and dermoscopic features. Evaluation with RCM showed features suggestive melanoma. Case: 71-year-old man presented for treatment of a verruca vulgaris, however, during the physical exam he was noted to have a pigmented lesion on the right cheek of unknown duration. The lesion presented as a light brown, well circumscribed and symmetric macule measuring 0.8 cm in diameter, with a focus of darker brown pigmentation in the center. The dermoscopic features of the lighter region of pigment were suggestive of solar lentigo, while the darker area revealed a thickened pigment network. The differential diagnosis included solar lentigo with focal lichen planus-like keratosis, pigmented actinic keratosis and melanoma in situ. Although suspicion for malignancy was relatively low, the central darker portion added an element of uncertainty. No other specific dermoscopic features for melanoma were observed other than a central thickened pigment network. RCM was performed as an additional diagnostic measure, revealing dendritic melanocytes in the basal layer, suggestive of a possible melanoma. A biopsy of the lesion was performed and was consistent with melanoma in situ. An interesting finding was that the pathology showed melanoma in situ of the entire lesion, not just the suspected darker central portion. Our case demonstrated the clinical utility of RCM for a challenging pigmented lesion on the face. While the presence of dendritic cells may also be seen in other lesions, such as inflammatory processes, this finding may be a clue to a more ominous diagnosis. In this case, RCM was helpful in providing additional information to support the biopsy.
Commercial support: None identified.

5492
Melanoma surveillance by multimode, hyperspectral dermoscopy and self-imaging using smartphone in high-risk patients Melanoma, the fastest growing cancer worldwide, kills more than one person every hour in the United States and costs more than $2.4 billion per year. Determining the depth and distribution of the dermal melanin noninvasively will help dermatologists to discriminate normal nevi versus melanoma. We developed a multimode dermoscopy system that combines polarization (cross and parallel), autofluorescence and hyperspectral (400-800 nm) imaging to noninvasively quantify and map in 3D, in vivo distribution of melanin, collagen and hemoglobin oxygenation in pigmented skin lesions. Hemoglobin and melanin spectra have significant overlap and systems that do not take this into account over/under estimate hemoglobin values (by a factor of up to 3) especially when analyzing nevi with high melanin concentration. Our molecular imaging approach can disentangle the hemoglobin and melanin absorptions leading to much more accurate hemoglobin measurement, independent of melanin absorption. By quantifying melanin concentration in pigmented areas, we can also remove the effect of melanin absorption from autofluorescence emission mainly from deeper collagen. We have also translated the knowledge and algorithms from our multimode hyperspectral image processing to improve detection and analysis using smartphone-based images by developing an optical attachment that provides wavelength and polarization conditioning. Image segmentation and analysis functions from the smartphone attachment automatically quantifies and reports biological features of nevi used in standard melanoma heuristics (ABCDE, and seven-point checklist) to a receiving dermatologist. We present molecular distribution maps as well as corresponding melanoma feature checklists derived from image analysis of twenty subjects with pigmented lesion. All patients were recruited as part of an ongoing IRB-approved study at the University of California Irvine. The resulting enhanced images will be employed to extract automatic quantification of melanoma checklist features that dermatologists can view online. By mapping melanin distribution in 3D we are able to estimate Breslow thickness in lesions of interest noninvasively. This could provide a new and valuable diagnostic tool in the detection and clinical management of melanoma. Introduction: Menkes disease o kinky hair disease is a rare lethal congenital X-linked neurodegenerative disorder based on essentials mutations in a copper transport gene (ATP7A). After 6 to 8 weeks of age this mutation leads to a copper deficiency which courses with the classical clinical features of mental retardation, seizures, failure to drive, hypotony, coarse hair, skin and joint laxity in males. We present a case of this rare disease. Clinical case: A 6 -year-old boy was initially evaluated at 13 months of age because of poor growth and development delay. He presented severe delayed psychomotor development, failure to drive with gastrostomy tube dependency. Physical examination showed bright skin, sparse, coarse, ivory gray hair, blue eyes, severe axial hypotony, big mouth with separated teeth, severe keratosis pilaris and multiples milia cysts in extremities and in the distal parts of the eyebrows. At the age or three the patient started with myoclonic epilepsy well controlled with valproic acid. Blood analysis revealed low blood levels of copper and cearuloplasmin. Cortical and subcortical atrophy as well as a marked cerebrovascular tortuosity in the circle of Willis was objectified by magnetic resonance. In trichogram, we observed pili torti and moniletrix. ATP7A gene analysis showed duplication in exons 5 and 6, predicted to be pathogenic of Menkes disease. It was started therapy with subcutaneous copper histidine with normalization of blood level of copper, but without any changes of the psychomotor development.
Discussion: Menkes disease has a poor prognosis with life expectancy of three to five years. Treatment with copper histidine is usually unsuccessful if not initiated in the first 6 weeks of life. Affected children have no specific features in the first weeks of life when treatment should be started. Healthy neonates present low serum copper levels as well as affected children. Twisted hair shafts (pili torti) are apparent after the first 2 months of life. Because of reduced copper depending melanin biosynthesis, affected children usually have less pigmented skin, hair and eyes like in our case. Conclusion: Early diagnosis of Menkes disease is essential to start copper therapy in the first weeks of life to improve neurological development and survival of affected children.
Commercial support: None identified.

4995
Mental disorders and dermatology: Sometimes together Maria Carmen Salazar-Nievas, Jaen Hospital; Aida Busaileh-Salas, Granada Clinic Introduction: Skin diseases are diagnosed mainly based on clinical appearance of the lesions and clinical history. Case report: A female of 56 years consult for painful and itchy lesions on the face and back of 10 days' duration. The exploration shows ulcerated lesions on the face and back. The patient is anxious and has emotional lability. He goes with her husband. Clinical suspicion is factitious dermatitis and the patient is derived to mental health. Comment: The management of patients with psychiatric disorders requires the dermatologist to be trained in mental illness. It is important to take care of the language used with these patients as well as knowing the management of major psychiatric disorders especially anxiety and depression. Numerous studies show that a high percentage of patients who visit the dermatologist has mental health problems.
Commercial support: None identified.
AB168 J AM ACAD DERMATOL JUNE 2017