- Email: [email protected]
Ultrasound diagnostics - German experience and educational politics
SlO
Syn~posi~ort
S4. New diagnostic
tehiqctes
get the correct diagnosis. Modern tools for skin visualization include color measurement and digital imaging. Skin color, hitherto described by simple adjectives can now be measured with instruments that provide reliable and reproducible data under physiologic and pathologic conditions. By quantifying erythema and pigmentation, skin color measurement enables the study of all conditions involving these two p‘arameter. It has been used to define phototype to identify subjects at risk for actinic cancer. Digital imaging applications range from simple recording and storage of dermatologic lesions to complex computer analysis by means of special algorithms. Computer analysis has been used to evaluate physiologic and pathologic skin phenomena, particularly high-risk pigmented lesions. This technique is likely to extend to many other sectors of dermatology, and perhaps we shall soon see the day when certain skin diseases can be directly diagnosed and followed by computerized analysis.
IS4-3
Dermatoscopy 1998 update, is it worthwile? The Copenhagen experience
H. Pehamberger. Viewto,
Viewra,
Departmeat Attstriu
of Dernratolugy,
of
University
Instrumentation of an initially purely clinical process - the early recognition of pigmented skin lesions (PSL) - has lead to a significant improvement of diagnostic sensitivity and specificity of detection of malignant melanoma. Applying epiluminescence microscopy the morphological features provided by this technique have to be read and interpreted by the observers. However, as with all instrumental methods, ELM needs some kind of training. Recently, it could be demonstrated that formal training is an important requisite to enhance the diagnostic accuracy of diagnosis. During the last years a new approach of ELM has been developed. Digital epiluminescence microscopy overcomes many drawbacks of this method in daily practice. Due to the electronic process of imaging, the observer has many possibilities of digital image enhancement. Electronic archival and retrieval systems of huge electronic images databases allow the follow-up of PSL. However, seveml studies ate needed to investigate the validity of this new technique.
IS4-4
Dermatoscopy (ELM) in the hands of “experts” and “non-experts”
Kaare Weismann, Henrik Lorentzen. Departnrent Derntato-venemlogy, Bispebjerg Hospital, University Copenhagen, DK-2400 Copetdtagerl, Denmark
of of
The incidence of malignant melanoma has increased within the last decades. A new diagnostic tool, dermatoscopy (ELM) has been introduced as a means to increase diagnostic performance in decision making regarding melanoma/non-melanoma. Few studies have dealt with the method’s application in clinical practice and its use by untrained clinicians. 232 pairs af clinical and dermatoscopic colour slides of pigmented skin lesions were evaluated by 4 “experts” and 5 “non-experts”. There were 49 cases of malignant melanoma (21%). Sensitivity was increased from 0.78 to 0.83 (p = 0.03) by “expert” dermatoscopy, whereas “non-experts” showed a decreased or unchanged performance (p=O.lS).
for
fire plnctising
denrmtolo@t
Positive likelihood ratio was doubled by dermatoscopy in the “expert” group, no improvement was achieved in the “nonexperts”. We conclude that formal training is indispensable for the correct use of dermatoscopy.
IS4-5
Non-invasive techniques for diagnosis and monitoring of skin diseases: An updating of recent techniques useful in dermatology
S. Seidenari. Dept. of Derrnatolagy,
University
of Moderra,
Italy
Besides the necessity of a realistic assessment of spontaneous course of diseases, the evaluation of the cost/benefit ratio of potentially new treatments is increasingly required. Objective documentation of dermatological disorders can be achieved by means of bioengineering techniques, which provide numerical values as a basis for statistical analysis and enable instant in vivo information in the absence of interferences with the spontaneous course of the disease. Erythema and induration in psoriasis, which are generally evaluated visually and by palpation, can be assessed by skin blood flow and colour measurements, and by ultrasound, respectively. Skin barrier damage in atopic dermatitis and irritant contact dermatitis can be determined by means of TEWL and hydration measurements, whereas spontaneous and experimentally-induced eczematous lesions can be evaluated both employing parameters of inflammation, obtained by ultrasound, laser-Doppler Rowmetry and calorimetry, and using hydration parameters (TEWL, capacitance). Increased skin thickness and modifications of skin echogenicity can be quantified by ultrasound, which, besides elastometry, provides a suitable means for the evaluation of localized and systemic scleroderma.
IS4-6
Ultrasound diagnostics - German experience and educational politics
K. Hoffmann, Andrea Hoffmann. Dermatological of Rtthr
University
Department
Gertttarly
Since the fundamental work of Alexander in 1979 high ftequency ultrasound has been developed to a standardized diagnostic tool in dermatology. By now 20 MHz Scanners are standard, we use two commercial available techniques (Dermascan C and DUB 20s). However, in addition our group works with two experimental 50 MHz and one 100 MHz scanners. Water is used as coupling medium between transducer and skin. Depending on employed frequency, bandwidth and other features of the system axial resolutions from 80 pm in 20 MHz sonography to about 10 pm in 100 MHz sonogmphy are achieved, the values for lateral resolution vary from 200 ,um to ~30 pm. Different imaging modi (A-, B-, C-scan, or 3D-mode) visualize the echographic information of the sampled tissue. In our group some thousend of patients with various skin tumors were examined sonographically followed by excisional biopsy. Exact correlating histological sections were used for correct interpretation of the sonograms. Among the different skin tumors malignant melanoma is of great interest because of its high malignancy and increasing incidence. Utilizing high frequency ultrasound tumor thickness of melanomas can measured in vivo rather exactly compared with Breslow’s thickness. This information ist very helpful in planning the therapeutical
Syn~posiun~ SS. Atopic
procedure (e.g. resection margin). Because other tumors also appear as echo-poor areas like melanomas differential diagnosis is very difficult - often impossible. Tumor parenchyma, tumor stroma, inflammatory infiltrates and skin appendices exhibits low echogenicity resulting in discrepancies between histological and sonographic measurements. 3D-images might better visualize topography, besides tumor volume and surface area can be quantified: these parameters may prove as prognostic indicators, Preoperative sonography of basal cell carcinomas echo-poor lesions, sometimes with a dorsal signal enhancement - facilitates the decision if cryosurgery can be applied or where the resection margins have to be placed. Sonography is an accurate and more objective technique for evaluating tumor regression or progression under therapy (e.g. Metastasis of Malignant Melanoma or Kaposi sarcoma treated with local or systemic chemotherapy). Although today differential diagnosis is not possible only by means of sonongraphy high resolution ultrasound should be applied preoperatively to visualize and quantify vertical and lateral tumor invasion. Since 1996 ultrasound is a MUST in the training for dematologists (board approval).
IS4-7
to the descriptive diagnosis afforded by CSSS, quantitative and/or dynamic aspects of skin biology can be explored by such approach. I S4-9 Routine measurement of sensitivity to light
as a basis for UV dosimetry and improved therapy
H.C. Wulf. Deparrtnettt Copenhagen,
Bispebjerg
of Dertttatology, Hospital,
University
of
Denmark
The sensitivity to ultraviolet radiation is normally determined by the minimal UV dose to elicit erythema. We have developed a reflectance measurement system that can predict the MED by measuring the pigmentation independent of redness. In this way, a direct measure of the expected dose to provoke erytbema can be estimated in a few seconds. We have shown that this measurement is an efficient guidance of the optimal dose for phototherapy and photochemotberapy. The number of PWA exposures for clearing psoriasis is significantly lowered by increasing initial UV doses in UVB photothempy. The cumulative dose for clearance of psoriasis and atopic dermatitis may be lowered by up to 65 per cent.
Diagnostic uses of tape and replica techniques in clinical dermatology
Gregor B.E. Jemec. Roskilde
Hospital,
Roskilde,
Detttttark
Tape and replica techniques have been used for many years in experimental and descriptive studies of skin, they are however also potentially useful in clinical dermatology. Tape techniques, including the D-Squame tapes@ and Sebutapeso are technically simple and can be used in the collection of warious microbes, in the assessment of scaling or to study sebum excretion. The use of replicas is more restricted. They are potentially most useful in the documentation of 3-dimensional changes of tissue, e.g. tumour remission following laser therapy. Replicas may however to some extent be replaced by 3-dimensional computer modelling as is being done in e.g. plastic surgery. Both techniques offer a higher level of objective record than classical clinical assessment. Throughout the world there is increased demand for quality assurance in clinical medicine, and both techniques may be of great use in this context.
IS4-8
Sll
dertttatitis
Cyanoacrylate skin surface stripping in clinical dermatology
G.E. Pierard, C. Pi&ard-Fmnchimont.
Lige,
Eelgiutn
Cyanoacrylate skin surface stripping (CSSS) is a time-honoured method to harvest a sheet of the superficial stratum comeum and follicular casts as well. Such minimally invasive sampling is currently used to assess various physiopathological alterations of the stratum corneum. It is a cheap and rapid method of diagnosis. The main indications are the differential diagnosis of erytbemato-squamous lesions. Spongiotic dermatoses, psoriasis, dermatophytoses. yeast and bacterial infections are conveniently distinguished. The distinction between malignant melanoma, benign melanocytic neoplasms and pigmented nonmelanocytic lesions can also be helped using CSSS. Further
S5.
Atopic dermatitis
S5-1 The role of keratinocytes in atopic dermatitis
=
(ADI
G. Girolomoni, Ittututt~ology, Rome, Italy
M.L. Giustizieri, S. Pastore. Laboratory Istituto
Dertnopatico
dell’lnuttacolata,
of IRCCS,
AD is the result of specific immune responses to allergens and of skin hyperreactivity to a variety of inflammatory stimuli. Keratinocytes (KC) can potently regulate both skin inflammmatory and immune responses. Our labomtory has shown that KC cultured from AD patients sythesize and release exaggemted amounts of GM-CSF, TNFIY, IL-la and IL-lra both spontaneously and in response to phorbol esters, IL-lo or IFN-)I. The enhanced production of GM-CSF and TNFa! by KC can be important for the recruitment and prolifemtion of dendritic cell (DC) precursors as well as in the functional activation and prolonged survival of DC in the skin, thus providing a powerful mechanism of persistent immune inflammation in AD skin. In addition, the programmed hyperproduction of proinflammatory cytokines by KC may favor initiation and persistence of nonspecific inflammation, and it can be relevant for targeting to the skin rather than to the respimtory mucosa clinical expression of the atopic state. Work is in progress to verify whether increased cytokine production by AD KC is secondary to a dysregulated activity of known transcription factors.
Syn~posi~ort
S4. New diagnostic
tehiqctes
get the correct diagnosis. Modern tools for skin visualization include color measurement and digital imaging. Skin color, hitherto described by simple adjectives can now be measured with instruments that provide reliable and reproducible data under physiologic and pathologic conditions. By quantifying erythema and pigmentation, skin color measurement enables the study of all conditions involving these two p‘arameter. It has been used to define phototype to identify subjects at risk for actinic cancer. Digital imaging applications range from simple recording and storage of dermatologic lesions to complex computer analysis by means of special algorithms. Computer analysis has been used to evaluate physiologic and pathologic skin phenomena, particularly high-risk pigmented lesions. This technique is likely to extend to many other sectors of dermatology, and perhaps we shall soon see the day when certain skin diseases can be directly diagnosed and followed by computerized analysis.
IS4-3
Dermatoscopy 1998 update, is it worthwile? The Copenhagen experience
H. Pehamberger. Viewto,
Viewra,
Departmeat Attstriu
of Dernratolugy,
of
University
Instrumentation of an initially purely clinical process - the early recognition of pigmented skin lesions (PSL) - has lead to a significant improvement of diagnostic sensitivity and specificity of detection of malignant melanoma. Applying epiluminescence microscopy the morphological features provided by this technique have to be read and interpreted by the observers. However, as with all instrumental methods, ELM needs some kind of training. Recently, it could be demonstrated that formal training is an important requisite to enhance the diagnostic accuracy of diagnosis. During the last years a new approach of ELM has been developed. Digital epiluminescence microscopy overcomes many drawbacks of this method in daily practice. Due to the electronic process of imaging, the observer has many possibilities of digital image enhancement. Electronic archival and retrieval systems of huge electronic images databases allow the follow-up of PSL. However, seveml studies ate needed to investigate the validity of this new technique.
IS4-4
Dermatoscopy (ELM) in the hands of “experts” and “non-experts”
Kaare Weismann, Henrik Lorentzen. Departnrent Derntato-venemlogy, Bispebjerg Hospital, University Copenhagen, DK-2400 Copetdtagerl, Denmark
of of
The incidence of malignant melanoma has increased within the last decades. A new diagnostic tool, dermatoscopy (ELM) has been introduced as a means to increase diagnostic performance in decision making regarding melanoma/non-melanoma. Few studies have dealt with the method’s application in clinical practice and its use by untrained clinicians. 232 pairs af clinical and dermatoscopic colour slides of pigmented skin lesions were evaluated by 4 “experts” and 5 “non-experts”. There were 49 cases of malignant melanoma (21%). Sensitivity was increased from 0.78 to 0.83 (p = 0.03) by “expert” dermatoscopy, whereas “non-experts” showed a decreased or unchanged performance (p=O.lS).
for
fire plnctising
denrmtolo@t
Positive likelihood ratio was doubled by dermatoscopy in the “expert” group, no improvement was achieved in the “nonexperts”. We conclude that formal training is indispensable for the correct use of dermatoscopy.
IS4-5
Non-invasive techniques for diagnosis and monitoring of skin diseases: An updating of recent techniques useful in dermatology
S. Seidenari. Dept. of Derrnatolagy,
University
of Moderra,
Italy
Besides the necessity of a realistic assessment of spontaneous course of diseases, the evaluation of the cost/benefit ratio of potentially new treatments is increasingly required. Objective documentation of dermatological disorders can be achieved by means of bioengineering techniques, which provide numerical values as a basis for statistical analysis and enable instant in vivo information in the absence of interferences with the spontaneous course of the disease. Erythema and induration in psoriasis, which are generally evaluated visually and by palpation, can be assessed by skin blood flow and colour measurements, and by ultrasound, respectively. Skin barrier damage in atopic dermatitis and irritant contact dermatitis can be determined by means of TEWL and hydration measurements, whereas spontaneous and experimentally-induced eczematous lesions can be evaluated both employing parameters of inflammation, obtained by ultrasound, laser-Doppler Rowmetry and calorimetry, and using hydration parameters (TEWL, capacitance). Increased skin thickness and modifications of skin echogenicity can be quantified by ultrasound, which, besides elastometry, provides a suitable means for the evaluation of localized and systemic scleroderma.
IS4-6
Ultrasound diagnostics - German experience and educational politics
K. Hoffmann, Andrea Hoffmann. Dermatological of Rtthr
University
Department
Gertttarly
Since the fundamental work of Alexander in 1979 high ftequency ultrasound has been developed to a standardized diagnostic tool in dermatology. By now 20 MHz Scanners are standard, we use two commercial available techniques (Dermascan C and DUB 20s). However, in addition our group works with two experimental 50 MHz and one 100 MHz scanners. Water is used as coupling medium between transducer and skin. Depending on employed frequency, bandwidth and other features of the system axial resolutions from 80 pm in 20 MHz sonography to about 10 pm in 100 MHz sonogmphy are achieved, the values for lateral resolution vary from 200 ,um to ~30 pm. Different imaging modi (A-, B-, C-scan, or 3D-mode) visualize the echographic information of the sampled tissue. In our group some thousend of patients with various skin tumors were examined sonographically followed by excisional biopsy. Exact correlating histological sections were used for correct interpretation of the sonograms. Among the different skin tumors malignant melanoma is of great interest because of its high malignancy and increasing incidence. Utilizing high frequency ultrasound tumor thickness of melanomas can measured in vivo rather exactly compared with Breslow’s thickness. This information ist very helpful in planning the therapeutical
Syn~posiun~ SS. Atopic
procedure (e.g. resection margin). Because other tumors also appear as echo-poor areas like melanomas differential diagnosis is very difficult - often impossible. Tumor parenchyma, tumor stroma, inflammatory infiltrates and skin appendices exhibits low echogenicity resulting in discrepancies between histological and sonographic measurements. 3D-images might better visualize topography, besides tumor volume and surface area can be quantified: these parameters may prove as prognostic indicators, Preoperative sonography of basal cell carcinomas echo-poor lesions, sometimes with a dorsal signal enhancement - facilitates the decision if cryosurgery can be applied or where the resection margins have to be placed. Sonography is an accurate and more objective technique for evaluating tumor regression or progression under therapy (e.g. Metastasis of Malignant Melanoma or Kaposi sarcoma treated with local or systemic chemotherapy). Although today differential diagnosis is not possible only by means of sonongraphy high resolution ultrasound should be applied preoperatively to visualize and quantify vertical and lateral tumor invasion. Since 1996 ultrasound is a MUST in the training for dematologists (board approval).
IS4-7
to the descriptive diagnosis afforded by CSSS, quantitative and/or dynamic aspects of skin biology can be explored by such approach. I S4-9 Routine measurement of sensitivity to light
as a basis for UV dosimetry and improved therapy
H.C. Wulf. Deparrtnettt Copenhagen,
Bispebjerg
of Dertttatology, Hospital,
University
of
Denmark
The sensitivity to ultraviolet radiation is normally determined by the minimal UV dose to elicit erythema. We have developed a reflectance measurement system that can predict the MED by measuring the pigmentation independent of redness. In this way, a direct measure of the expected dose to provoke erytbema can be estimated in a few seconds. We have shown that this measurement is an efficient guidance of the optimal dose for phototherapy and photochemotberapy. The number of PWA exposures for clearing psoriasis is significantly lowered by increasing initial UV doses in UVB photothempy. The cumulative dose for clearance of psoriasis and atopic dermatitis may be lowered by up to 65 per cent.
Diagnostic uses of tape and replica techniques in clinical dermatology
Gregor B.E. Jemec. Roskilde
Hospital,
Roskilde,
Detttttark
Tape and replica techniques have been used for many years in experimental and descriptive studies of skin, they are however also potentially useful in clinical dermatology. Tape techniques, including the D-Squame tapes@ and Sebutapeso are technically simple and can be used in the collection of warious microbes, in the assessment of scaling or to study sebum excretion. The use of replicas is more restricted. They are potentially most useful in the documentation of 3-dimensional changes of tissue, e.g. tumour remission following laser therapy. Replicas may however to some extent be replaced by 3-dimensional computer modelling as is being done in e.g. plastic surgery. Both techniques offer a higher level of objective record than classical clinical assessment. Throughout the world there is increased demand for quality assurance in clinical medicine, and both techniques may be of great use in this context.
IS4-8
Sll
dertttatitis
Cyanoacrylate skin surface stripping in clinical dermatology
G.E. Pierard, C. Pi&ard-Fmnchimont.
Lige,
Eelgiutn
Cyanoacrylate skin surface stripping (CSSS) is a time-honoured method to harvest a sheet of the superficial stratum comeum and follicular casts as well. Such minimally invasive sampling is currently used to assess various physiopathological alterations of the stratum corneum. It is a cheap and rapid method of diagnosis. The main indications are the differential diagnosis of erytbemato-squamous lesions. Spongiotic dermatoses, psoriasis, dermatophytoses. yeast and bacterial infections are conveniently distinguished. The distinction between malignant melanoma, benign melanocytic neoplasms and pigmented nonmelanocytic lesions can also be helped using CSSS. Further
S5.
Atopic dermatitis
S5-1 The role of keratinocytes in atopic dermatitis
=
(ADI
G. Girolomoni, Ittututt~ology, Rome, Italy
M.L. Giustizieri, S. Pastore. Laboratory Istituto
Dertnopatico
dell’lnuttacolata,
of IRCCS,
AD is the result of specific immune responses to allergens and of skin hyperreactivity to a variety of inflammatory stimuli. Keratinocytes (KC) can potently regulate both skin inflammmatory and immune responses. Our labomtory has shown that KC cultured from AD patients sythesize and release exaggemted amounts of GM-CSF, TNFIY, IL-la and IL-lra both spontaneously and in response to phorbol esters, IL-lo or IFN-)I. The enhanced production of GM-CSF and TNFa! by KC can be important for the recruitment and prolifemtion of dendritic cell (DC) precursors as well as in the functional activation and prolonged survival of DC in the skin, thus providing a powerful mechanism of persistent immune inflammation in AD skin. In addition, the programmed hyperproduction of proinflammatory cytokines by KC may favor initiation and persistence of nonspecific inflammation, and it can be relevant for targeting to the skin rather than to the respimtory mucosa clinical expression of the atopic state. Work is in progress to verify whether increased cytokine production by AD KC is secondary to a dysregulated activity of known transcription factors.