New technology holds promise in detecting lesions, diagnosing melanomas

Jane M. Grant-Kels, MD

‘My big concern is that the technologies will go by the wayside because the federal government and the insurers won’t give them a code,’ Jane M. Grant-Kels, MD, said. ‘In spite of that, I hope that dermatologists will embrace these new technologies because they are good for the patient.’

Much of the focus for reducing the growing threat of melanoma has been on health care professionals screening patients. Dermatologists can lead this effort by stepping up their own screening efforts and supplementing those efforts with increased use of dermoscopy and developing technology, such as total body imaging, confocal microscopy, and multispectral imaging with computer assistance.

Jane M. Grant-Kels, MD, discussed the potential of these efforts Friday in her Plenary presentation, “Melanoma and Pigmented Lesions, Update on Diagnosis.” She is the Dermatology Department chair, professor of dermatology, pathology, and pediatrics, director of dermatopathology, and director of the Cutaneous Oncology Center and Melanoma Program at UConn Health.

“The clinical diagnostic accuracy for melanomas still is only about 80 percent. Because we can’t diagnose melanoma clinically 100 percent of the time, we do many biopsies,” Dr. Grant-Kels said. “To get one melanoma, we do many biopsies of benign lesions. Our biopsy ratio is not great, so the question is, ‘What do we have available to us now or in the near future that is going to enhance our diagnostic abilities so when we do biopsy, the ratio of melanoma to numbers of biopsies will be closer to one-to-one?’”

A starting point in improving diagnosis is to perform full skin exams on all patients. A 2010 survey of patients showed that fewer than 11 percent had a full skin exam by their physicians in the last year. Less than one-third of dermatologists surveyed said they performed full-body skin exams on all of their patients.

“How do you diagnose melanoma? The first thing is to actually examine a patient’s entire skin surface,” Dr. Grant-Kels said. “That is not a new technique, but it is something all dermatologists should be doing regularly on most, if not all, of their patients.”

Another helpful tool, especially for high-risk patients, is total body digital imaging.

“Newer technologies will allow patients to enter a confined, secure area and hold a few positions to get total body imaging of their skin that is quite accurate and reproducible in less than 10 minutes,” Dr. Grant-Kels said. “It is all standardized with proper lighting and focus, resulting in high-quality images.”

Once a set of baseline images of the skin surface are captured digitally, the patient can return if any problem areas are found so those areas can be re-imaged. The two sets of photos can then be compared to determine if there are any changes. Frequency of return visits and re-imaging is variable depending on the patient’s past medical history and risks.

“This is new technology that is not commercially available but is coming down the road,” Dr. Grant-Kels said, while showing photos of the equipment. “A flicker technique allows you to compare images by going from one to the other to determine whether there has been a change. It’s really exciting technology.”

Another method of evaluating skin lesions is dermoscopy, which has been available for more than 30 years. According to a study published in 2010 in the Journal of the American Academy of Dermatology, less than half of all dermatologist surveyed were using dermoscopy (Warshaw. JAAD 2010;63:412). However, Dr. Grant-Kels also cited a 2014 survey recently published in JAAD that 80.7 percent of dermatologists are now using dermoscopy; the use of dermoscopy appeared to be the most common in the younger dermatologists who had been trained in its use. However, only 31.3 percent of dermatologists in this survey reported using dermoscopy on all pigmented lesions, and only 49.3 percent use sequential dermoscopy to follow changes in individual lesions (Murzaku, et al. JAAD 2014;71:393

“There is evidence that dermoscopy can improve your diagnostic skills by about 50 percent,” Dr. Grant-Kels said. “Although it requires some skill, by using pattern recognition, dermoscopy should improve a dermatologist’s diagnostic acumen very quickly.”

Newer technology that could reduce or replace biopsies is confocal microscopy, which Dr. Grant-Kels demonstrated in photos and described as a bridge between dermoscopy and histology.

“By using a laser light and capturing images reflected back from the skin surface, you can get images of the skin in cross-section where you see the skin cells,” she said. “This could some day be a replacement for many skin biopsies done to rule out malignancy, or determine margins of a tumor or treatment outcomes.”

Another new tool is multispectral imaging with computer assistance. These devices use various wavelengths of light that are reflected off the skin. One of these devices uses 10 wavelengths of light and 75 computer algorithms to analyze the image to determine if a lesion could be problematic.

“It does not tell you to biopsy or not biopsy, but it gives you a percentage of the risk — whether the lesion is likely to be malignant or benign. This can obviously be very useful when a patient will not let you biopsy, when you are not sure if you should biopsy, or when it is a facial lesion and a biopsy has significant consequences, like a scar on the face,” Dr. Grant-Kels said. “A low score is very reassuring that the lesion does not need to be biopsied. A higher score suggests that a biopsy may be indicated.”

Dr. Grant-Kels also discussed the use of electrical impedance spectroscopy (EIS) in distinguishing benign from malignant skin lesions. EIS measures overall resistance of tissue to alternating currents at various frequencies. Malignant cells impede current differently than benign cells allowing differentiation between melanoma and other, benign skin lesions.lns.

Despite the great potential of these new technologies, they have not come into general use because billing codes for these have not been developed, which is a roadblock to reimbursement, she said.

“My big concern is that the technologies will go by the wayside because the federal government and the insurers won’t give them a code,” Dr. Grant-Kels said. “In spite of that, I hope that dermatologists will embrace these new technologies because they are good for the patient.”

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