Dr. Travis Blalock summarizes the benefits of dermoscopy in aiding clinicians in the diagnosis of melanoma using visual examples to assist learners in identifying the difference between malignant and benign lesions.
Our next speaker is Travis Blaylock. Travis is the director of dermatologic surgery, mose and continuous oncology at the at Emory. He did a fellowship with Dr Greenway at the Scripps Clinic in most surgery. And he's going to cover DeMoss copy and new diagnostic techniques for us. Travis. Right. Thanks for the kind Introduction terry. Um My name is Travis Blaylock and here we go. Um So today I'm going to talk about DeMoss copy and new diagnostic techniques. I think a lot of this stuff, thankfully many of you will be familiar with. Um but excitingly there's a lot of new diagnostic techniques that will be kind of percolating out in the next coming years and I hope we'll add some benefit to our ability to make these diagnostic uh efforts in the next couple of years a little bit more fruitful and more effective. These are my disclosures would have nothing to do with what we're going to talk about today. So the first thing I just wanted to say is that, you know, this is Arthur Conan Doyle, who was the writer of the Sherlock Holmes series. And one thing that always kind of pointed out in this particular quote is that a lot of the features and the factors that that we look for in melanoma are not things that have occurred by happenstance. People have looked for them specifically and intentionally and what you'll find, especially when it comes to DeMoss copy and many of the other diagnostic techniques that we're looking at today is that you have to intentionally look for them. So I would challenge you to try to get into a habit of looking for some of these features and factors that we commonly are tested on and reminded of. But if we're not thinking about them on a daily basis and were many times going to be missing some of these features that might allow us to actually help patients. So you might wonder why diagnosed early. Many of these things are probably well known to many of the people in the audience, but not surprisingly, delays. And diagnosis correlate with advanced stage melanoma. Just looking clearly at the photograph for the image to the right indicating that advanced stage melanoma essentially induces increased risk of morbidity and mortality. Um and that plays out in in downstream even into the amount of health care dollars that we spend on treating diagnosing. Um and living with melanomas. So diagnosing early is is quite an obvious thing for us to be considering to doing Now. I know that Dr Patterson talked a lot about some of the epidemiology but it becomes very clear that with the increased number of invasive melanomas diagnosed over the course of history that we will be dealing with what to do with these melanomas. And I'm going to leave that to other speakers coming but suffice it to say that the numbers are increasing and we will be seeing these patients in our office with a diagnosis. Um but hopefully we will be able to catch these patients a little bit earlier And I did throw this one epidemiologic fact at the bottom, which I think is really important. We tend to think of melanoma as being a male dominated diagnosis and it is, but before the age of 50, the rates are actually hiring women. So I would throw that out. There is a, a reminder that melanoma does not necessarily see age as a limitation for it to actually induce some negative outcomes. So I continue to leave this particular slide in here, just because it is a reminder for me of a lot of the challenges that we faced in melanoma over the years and some of the indications that maybe we're actually making some ground and not only in regards to the treatment of which we're going to hear about from over the course of the next two days, but also in regards to diagnosis, were clearly diagnosing more melanomas. Um, but you know, when I first started giving this lecture, one of the negative things that I remember was that melanoma induced a significant healthcare burden from the context of morbidity and mortality, as well as from the economic cost associated with the treatment, as well as the diagnosis of melanoma. And that's in comparison to some of the really commonly discussed, uh, can't diagnosis of cancer that typically we associate with really bad mortality, including colon cancer, prostate cancer and breast cancer. So I think one of the really great things and I'm sure someone else will talk about this. One of the really exciting things that we're seeing over the past four or five years is that the number of estimated deaths is actually dropping. And I think that's an indication that we're doing something in our trajectory is positive, both in the treatment as well as hopefully from the diagnostic standpoint, we're going to focus mostly on diagnosis today. However, you know, as Ben franklin once said, you know, an ounce of prevention is worth a pound of cure. I think we would be remiss if we didn't talk a little bit about primary prevention, which is a little bit difficult for us to discuss because there is unsettled ideology of melanoma, you know, we talk about whether it's viral, whether it's genetic, whether ultraviolet light has something to do with whether there are environmental factors. And I think even if you just looked at skin of color patients who have typically melanomas in april sites and the known as genetic associations there, we have to recognize that there are many different factors that are, we should consider when it comes to the ideology of melanoma and whether it's multifactorial is definitely a discussion that we can have. But suffice it to say there is an association between UV exposure in melanoma and I believe dr y song is going to follow my lecture and talking a little bit more specifically about that. But even if you just look at some of the older data, total sun exposure, chronic exposure and sunburn history are things that are associated with increased risk for cutaneous melanoma. And it would be who of us for us to not consider giving patients in primary prevention and cautionary things that they can do to prevent melanoma. But the focus of this talk is diagnostic techniques as well as DeMoss copy. And I'd like to think of this or at least break it up in the context of the things that we do have versus the things that we need. And taking into considering consideration those things that we already use many of these diagnostic techniques for. So for example, you know what we really want is to throw all of these things into a crystal ball, take a pigmented lesion into a crystal ball and have them tell us what the biologic potential or the biologic outcome is going to be. We're not quite there yet. And in reality, as discussed here recently on the previous lecture was that histology is still the gold standard um Durmus copy and many of the other diagnostic modalities that we're going to discuss can improve the clinical examination and those, those diagnostic modalities including the Moscow. We provide a lot more information to convey the pathology so that they can provide us some assessment of what the biologic nature of what they see under the microscope truly will be. But it forces us to have at least a consideration for just a moment as to whether or not histology should be the gold standard for biologic behavior, especially considering the variability and reproduce the reproducibility as well as accuracy as highlighted by this article at the bottom. But as of now, I think we have to recognize that histology is the gold standard, but there are some things that we can do and I suspect as things progress in this particular field, we may come to question whether or not histology is the gold standard and truthfully this is what we want and we're not quite there yet quite there yet. But I think we're moving in that direction. Um I suspect many of us have gone to many of the pharmacies and seeing really you can pick up a box and evaluate your own genetics pretty quickly over a course of weeks with just a little swab of your mouth. But I think what we're moving towards in dermatology and this was a study that came out just a couple of years ago, a development of a non invasive to gene molecular ass A for cutaneous melanoma where we take a piece of tape and take off a little bit of skin over the top of a pigmented lesion and send that off and someone will provide us an analysis in this particular paper. They they evaluated two genes specifically, including the prime gene, which was discussed in the previous talk. Is it perfect. No, but it does provide some sensitivity and specificity. Um, that is moving us in that right trajectory. We were discussing to be determined as to how that will play out. But what tools are currently are available. We clearly provide patients with education regarding self skin examinations. We bring patients in on a regular basis for our examination of their skin, whether that includes derma telescopic evaluation or digital mole mapping. And then there are some more high tech things that have come out over the past 20 years that that have assisted us in our ability to make a good diagnosis for patients with pigmented lesions, including things like con focal microscopy, multispectral, digital Durmus copy as well as computer based analysis. We're going to talk a little bit about electrical impedance spectroscopy because I think that's relatively new. And then other speakers will speak to his to pathologic evaluation as well as molecular analyses and essays that will allow us to make these diagnoses more clear and more specific. And so that's why we're going to focus on these seven. So self skin examination. You know, I used to give this talk and I used to say it's free. Um and one of the attendees rightfully so pointed out that this is not specifically a free uh concept and certainly patients can do this in the comfort and privacy of their own homes, but we have to be able to teach this and teaching patients what is a mole in teaching patients what they're supposed to be looked at comes with a cost, whether that's time or finances. But it is a relatively inexpensive way for us to teach patients how to look at their lesions and evaluate their lesions so that they can contribute to their care. And contributing to their care is really important, especially in the context that a lot of the data suggests that self skin exams are associated with thinner melanomas. And self skin exams may decrease death from melanomas by upwards of 63%. So those things are important and from a very pragmatic and practical reason, patients doing stine self examinations, it may be extremely helpful, especially considering the fact that access to care is a challenge for many places across the country, and most melanomas show changes over a period of 3 to 6 months in bringing patients in on a 3 to 6 month basis, sometimes is unfeasible. And so providing patients with the tools and the abilities uh for what Gene Robinson has has proven is a teachable skill, I think is a very important tool for us to be able to give our patients and allow them to do. And then probably on this call are on this discussion today. I suspect many of the people in the audience are discussing and thinking about how they can provide better physician skin examinations. Um and a lot of this has historical context, as was indicated by dr patterson earlier uh Dr. Breslow in 1970s indicated depth of invasion makes a difference. And this is important for us, especially considering the fact that we know that if we can palpate a lesion that may give us an indication of the depth of the lesion and that may have indications for prognosis as well as what we need to do for intervention. As well as doing the biopsy. Now from a from a clinical lesion beyond just palpitating lesion. Y you indicated that maybe we need to provide some guidelines for evaluation of pigmented lesions and that's where at least in the time frame in which the A. B. C. D. S came along. And these are things that we are well aware of. And then this was expanded In the 90s to include an E. & F. F. For funny and E. For evolving. Um And there are some definitely some side bars that are associated with funny looking moles, including people who have considered the thing called the ugly duckling sign, which is an indication that patients who come in with an isolated lesion, uh and no other moles, maybe that one might be a little bit out of place. Or maybe someone comes in with many moles and they have one that looks significantly darker, significantly lighter in a significant different um uh symmetry than the others. Maybe those are lesions that we need to be mindful of and evaluating for. But physician skin exams definitely may not necessarily be the end all be all. But they can do things that a patient skin exam cannot. And that's including seeing patients that the patient can't see. Our won't be able to evaluate patients who have significant others who can look in places that the patient can't see. Very helpful to the self skin exam. But in cases where those those people are not available, the physician skin exam really feels the need in a niche for finding and evaluating pigmented lesions. But the goal for us really is for us to biopsy enough lesions to make the diagnosis all the time while minimizing unnecessary biopsies. And I suspect that many of the things that we're going to talk about in the remainder of this talk will hopefully move us in that direction. So, we're gonna talk initially about DeMoss copy or dermatitis copy. Historically. We've had a pre conference more intense discussion of what this is, but I wanted to delay a little bit of the groundwork just in case people were interested in getting in on the ground level and starting an effort of learning more about Durmus copy because it can improve the sensitivity of your ability to visually detect a melanoma. It allows detection of a lesion displaying classical features described as a B C D. E. F. That we talked about in the previous slide and this may allow us to catch some melanomas earlier than before. They actually display those clinical characteristics which will subsequently lead to earlier detection of melanoma. And as we talked about earlier that will ultimately indicate our ability to decrease morbidity and mortality and health care costs that come with diagnosis of melanoma at a later stage. Now the question really becomes, is dermatitis copy the first flying tool or is it a supplement to clinical exam in some sense? I think it's a false question, but I think you have to recognize that the dermatology copy or DeMoss copy many of the skills and arts that are associated with evaluating lesions through a dramatic scope are things that we have been doing for years and cataloging a neural network within your own brain of what a pigmented lesion is supposed to look like and what are some of the concerning features. Um those are things that we really need to acquire over over years and and doing it. So, you know, I would just drive home the point that dermatitis copy is one of those things where it's not like some of the other modalities that we'll talk about. You can't pick it up off the shelf and know exactly how to use it. It takes time, but it's still at this point not as reliable to microscopic examination and I would say at least as at least as a sidebar. In regards to that point that the reality is, the more you do this, the more likely we are to get towards being reliable as something as a microscopic examination. But we're not quite there yet. But dumas copy while over the past 20 or 30 years has become kind of a standard discussion and an educational value in residencies and fellowships across the country. It is not a new concept. In fact, Leon Goldman, one of the pioneers of laser therapy, talked about being able to see some of these smaller microscopic features at moderate magnification and how those features may allow us or guide us in our diagnostic evaluation and treatment modalities for lesions. And in this particular photograph, he's showing some of the features that we commonly see with separate keratosis. And in the second photograph showing some of the microscopic features are dramatic opic features, magnification features that we would see in a basil cell, including the telly inject asia's. And so instead of going through every single thing on every single diagnostic uh way that you can evaluate uh pigmented lesions for democracy, I'm going to show you what I use and the concepts that I use and hopefully this will give you at least some framework from which to embark on your own dramatics coptic education. So, first, you know, I would drive you to at least consider this particular paper which I think sets up some of the fundamentals of looking at things from a dramatic opic perspective. And I don't think they change or that much different um that this is that much different than what we're doing on a clinical patients without without the demography. Um but the first step that I take when I look at a pig or a lesion on the patient's skin, is this a milan acidic lesion? Or is this not a mill anesthetic lesion? Because it may change the way in which I biopsy something the way which I may diagnose something in the way english, we may treat something. But since we're going to talk specifically about the pigmented lesions, we're going to go in that in that route. But I would point you to this paper that kind of focuses on some of the differentiating factors when you're looking at something through a dramatic scope. Some things that might drive you to think that something is a milan acidic lesion like aggregated globules and streaks, which can be characterized on this on this photograph or some that are probably more commonly known to many of the people on this uh discussion today, including Thailand dictations which are commonly seen with basal cell carcinomas or commodore like openings that you'll find with separate keratosis. But once you've determined that this is a pigmented lesion, it's not quite we're not quite done with this discussion because the reality is we want to take those pigmented lesions and more clinically characteristics, whether or not they're likely to be benign or if they are malignant because if they are benign, then maybe we can avoid a biopsy that would be unnecessary or if they are malignant, we would be able to move forward with their treatment. And so this would be the 2nd 2nd step in this algorithm. Now, this is the part where people sometimes get lost and rightfully so because many people have come up with different methods for the diagnosis of melanoma by DeMoss copy. In fact, if you look at this consensus statement, you'll recognize there are many different ways and methods for people to take a pigmented lesion and determine whether it is likely to be benign or malignant and the reality is whichever one you choose is probably okay because the sensitivity is relatively similar no matter which one you choose. Now, if you focus on the outcome of this paper, you'll recognize that the pattern analysis definitely showed greater specificity. But as you get involved with trying to figure out how you would like to deploy DeMoss copy in your own clinics, I would try to figure out which one is most likely to be done in your clinics because as you'll notice in the next few steps that I talk about the more common ways that we will use to Moscow p to diagnose mechanistic lesions. Some of these are likely to be practical in your clinics in some of these may not be. So the first one is the pattern analysis which if you remember, I told you is probably the one that is the most specific. It is understanding many of the features, including global features and local features that you might see under dramatic scope which might lead you into making a diagnosis of melanoma. How many of these are very well known to many of us, including the blue white veil that you commonly see with melanomas. Regression structures that we commonly see with melanomas. Um And there are the star burst patterns which would commonly see in spits nearby. But the reality is looking at a lot of these lesions and understanding the terminology and being able to characterize and identify them under dramatic scope requires looking at a lot of lesions. And so this is a perfectly fine way of evaluating a pigmented lesion um dramatic optically but can be somewhat overwhelming for someone really just getting into their drama to stop their dramatic opic field. The second option I really liked initially because it is called the A. B. C. D. Rule for evaluating pigmented lesions via DeMoss copy. And the reason it was very simple is because it correlates very strongly with the common characteristics that we look at for pigmented lesions without a dramatic scope including a symmetry border color or we typically use diameter with this is dramatic opic structures. My only challenge with this particular particular concept is that it requires some calculations. Um And those calculations are not necessarily at least in my mind quite as straightforward and specific. Very specific but not straightforward and easy to deploy in a clinic. Um And so while this may be a very good way to remember what are the most dramatic Skopje criteria for the A. B. C. D. S. Um It may not be as as deployable in your clinics because of the trigonometry required. Now the next one is called the mindy scoring method which I tend to like as well. Um It shows some negative features as well as some positive features, many of which are are ones that we've we've talked about in the past including the blue blue gray dots and white veils et cetera. But I won't focus too much on that. And then the one I wanted to talk a little bit about today is the one that I tipped tend to use and that is the seven point checklist. It sounds like a lot but it's not as challenging in regards to making the the calculations. Um And there's a little bit more understandable I think to most people starting out um It talks about a typical pigment networks as well as the blue white veil and a typical vascular patterns as being strong indicators and indicators for us to consider biopsy a lesion and those are counted as having two points, whereas irregular streaks, irregular dots and global's irregular blotches and regression structures all have one uh point ascribed to them in this particular calculation. Um And so you need three points to indicate a biopsy and I tend to like this one. So the seven point checklist, The three major criteria as we indicated. And you can look at, there's many books that will highlight these features and get you more comfortable with identifying them more clearly. And then you hear the four minor criteria of which you can see in these photos and you can review later. So dermatitis copy is one of those things where, like I said, you just need to do this a lot and eventually maybe you'll be able to see the three dimensional structure that that I keep trying to see in some of these photographs that used to be very popular on the right. So we're beyond DeMoss copy. There are many other modalities for melanoma detection and I'd point you to this paper which is a little bit dated, but most if not all of the technology is still fundamentally used um albeit at less or so rates on some of these higher technology type things. But these are the next best thing and I suspect will become more common in the future, including things like con focal microscopy, which has seen a large push over the past 8 to 10 years. Digital mole mapping is something that we do here at Emory and I think it's variable as to whether or not. Um, it's utilized in your particular location, but it is a way for us to see individual lesions a particular area of the body or the entire body. A lot of people will use dramatic scopes or dermatitis copy images to see individual changes for lesions that they're concerned about. But there continue to be concerns regarding the employment of this particular modality because of variations equality. The need to maintain these records and what patients are supposed to do with them. Our patients supposed to monitor themselves. Do patients come in when they see a change? And so the question really becomes, is that time saving, is it cost saving? And ultimately we really need to figure out is whether or not it's life saving or more morbidity saving. And the other thing that I would throw out there is that even Menzies who has the namesake for the earlier dramatic opic um discussion. It indicates that three months remains the standard interval for where in which the sensitivity of the diagnosis from melanoma uh Is high but not 100%. So are we going to bring patients in every three months? I think typically that would not be the norm. And so we need to figure out a way to get patients involved and do that in a way that is not onerous on the system and does not decrease our ability to provide access to care. I won't spend too much time on Multispectral digital DeMoss copy which at least historically over the past 10, 15 years has been the elephant device which was FDA approved. It has got really good sensitivity compared to some other modalities. Um, specificity is not that bad either, but it requires training. Its cost has been has been a barrier for people to deploy this in their in their clinics. But suffice it to say it looks almost like a remote control and it analyzes features that we simply can't see with the human eye um and evaluates those in comparison to a catalogue of pigmented lesions that have been integrated into its database. But I think over the next few years, what will recognize is that we will have an increased number of modalities and technologies that are similar where we are using deep neural networks uh to determine whether or not a pigmented lesion is concerning enough to require biopsy or further intervention. And the results of deep learning networks is not a new concept over the past year or two. But there is a significant concern that we will have an increased number of pigmented lesions for which we will need to provide care. As some of these deep learning computer vision systems are classifying melanoma as um that exceeds some but not all dermatologists and these are becoming more and more normal. The last thing I'll talk to you about is something that is relatively new over the past few years. Um and that is electrical impedance spectroscopy in skin cancer diagnosis. And I would say at least starting off that this is a new technology that I think is meant to supplement our clinical exam. In fact, if you look at some of the authors on this particular article, you'll notice that many of them are the pioneers in Durmus copy and so we're trying to do anything and everything that we can do to try to determine which pigmented lesions require intervention. But this is a non imaging based technology that is an FDA approved Class three technology for evaluation of melanoma, placing these electrodes on the skin and using electrical impedance spectroscopy to determine if a particular lesion has characteristics that would require intervention and it has a sensitivity. Again, that is very, very high specificity is not quite as high, but still not something to scoff at. And it's negative predictive value is 98 to 99% which rivals some, some clinicians and practitioners out there. So we need to be mindful that it's not simply just imaging, it's not DeMoss copy, it's not just a clinical exam. I think the future probably holds a variability of all of those things. If not if not all of those things for us to evaluate lesions more specifically, um and provide better care for our patients. So a lot of this is going to require a lot of hard work and I would suggest that many of these modalities while they may not be at their final form, we will we will be providing those in our practice and we will be deploying those in our practice in the years to come. So I think the Onus is on us for us to do some of the hard work to try to figure out how we're going to make those provide better care, including some of the things that require us to do things on our own, including DeMoss, copy and understanding those techniques more effectively. So with that I will turn over to dr Barrett. Thank you scott. Very nice presentation. We uh we're a bit over time so we'll just take the questions and forward them to you. And we also have some questions come in late for previous speakers and again, those will be forwarded on and we'll all get answered tomorrow. So I appreciate your presentation. Thank you doctor.
