The purpose of this project was to evaluate the effectiveness of a practice-based dermoscopy training program for dermatology healthcare providers in order to improve their technique of performing clinical skin exams for the early detection of melanomas. The overall incidence of melanoma continues to rise. More than 75% of all skin cancer deaths are from melanoma. Advanced melanoma spreads to lymph nodes and internal organs and can result in death. One American dies from melanoma almost every hour (American Cancer Society [ACS], 2009). Early diagnosis and excision are essential to reduce morbidity and to improve patient survival. This one-group before-and-after study design utilized a convenience sample of three dermatology healthcare providers (DHPs). The primary investigator conducted a retrospective review of the pathology logs for each provider. The time frame for the review was a three-month period in 2010, which represented the same time frame that the study was conducted in 2011. The DHPs participated in a four-hour training workshop that included pattern analysis recognition using dermoscopy. Following the workshop, each DHP was given a DermLite 3Gen DL100 to use in practice when performing clinical skin examinations. All DHPs completed a data collection sheet to document their pattern of decision making with and without a DermLite. The outcome of interest was the use of dermoscopy by DHPs to demonstrate an increased detection of melanoma when compared to naked-eye examination. The outcome was evaluated 12 weeks postworkshop training. There were 120 evaluations made with the DermLite as compared to the naked eye. The overall agreement was 0.52, AC1 coefficient (95% CI) was 0.36 (0.30, 0.42), p < .001, and kappa coefficient (95% CI) was 0.27 (0.20, 0.43), p < .001. Overall, the risk of lesion under exam being suspicion for skin cancer was higher on 27.5% (33 out of 120) of the evaluations and lower on 20.8% (25 out of 120) evaluations. The risk of lesion was evaluated the same on 51.7% (62 out of 120) of the evaluations. This is an indication of “Poor” agreement between the two methods. The diagnosis and disposition made using DermLite compared to naked-eye results for both coefficients provided an “Intermediate to Good” agreement between the two methods in assigning diagnosis and disposition. This indicates that there is no difference between DermLite and naked-eye evaluations. More studies are needed in order to provide better evidence on the value of dermoscopy in clinical practice at the Dermatology and Laser Center. Future projects should be more explicit regarding the methods used and lesion selection in order to better understand the benefits of dermoscopy.

<p>Увод. Базоцелуларни карцином коже (БЦК) је спорорастући малигни епидермални тумор. овај најчешћи тумор у људи иако врло ниског метастатског потенцијала може бити високо инвазиван и значајно допринети морбидитету, угрозити функцију и естетику регије, па и сам живот. Лечење БЦК има за циљ: уклањање тумора, очување здравог ткива и функције, оптимални козметски резултат. Најчешћи вид лечења БЦК је једноставна хируршка ексцизија. Према важећим препорукама БЦК се ексцидирају са заштитним маргинама од 5-10 mm. Одређени броју студија показују директно или индиректно да је клинички одређена маргина врло слична реалној. Оцена адекватности клиничке процене у односу на хистолошку маргину тумора није довољно испитивана. Стопа комплетне ексцизије БЦК (излечење) се не повећава значајно са повећањем сигурносне маргине Циљ истраживања је установљавање односа повезаности између клиничке процене и микроскопски утврђене латералне маргине БЦК на хистолошком препарату. Методологија. У обради узорка од 45 испитаника узети су циљани анамнестички подаци, спроведен клинички преглед, уобичајена хируршке терапије и класична патохистолошка обрада узорака. У методолошкој обради 60 узорака тумора интраоперативно врхом хируршког скалпела целом циркумференцијом клиничке маргине тумора начињен је зарез до нивоа папиларног дермиса. Пре ексцизије додата је заштитна маргина од 4-5 mm. Класична патохистолошка обрада је спроведена као и преглед препарата светлосним микроскопом различитог увеличања (х 40, х 100, х 200, х400). Мерење дистанце између начињеног зареза, и хистолошке границе тумора вршена је уз помоћ милиметарског окулара. Сви добијени подаци унети су у заједничку базу података. За статистичку обраду података коришћен је програм СПСС 21. Коришћене су методе методе дескриптивне статистике, униваријантне и мултивасријантне анализе. Резултати су приказани табеларно и графички, а комплетан рад је обрађен у текст процесору MS Word. Резултати. У 96,7% ексцидираних БЦК удаљеност зареза од патохистолошке маргине тумора је мања од 2,0 мм, док је у два тумора (3,3%) зарез на удаљености 2 и преко 2мм. У четвртини узорка (25%) зарез се налази у тумору, а 75% узорка зарез је начињен ван хистолошке границе тумора. Закључак. Разлика између клинички обележене и микроскопом измерене латералне маргине је у више од 95%, односно у 96,7% мања од 2 mm. У 88,4% случајева ова разлика у процени је 1mm или мање од 1mm. Постоји позитивна корелација између клинички процењене и патохистолошки одређене латералне маргине БЦК. Иако се поједини предиктивни фактори који утичу на лошију клиничку процену могу издвојити, истраживање није показало статистичи значајне предиктивне факторе.</p> / <p>Uvod. Bazocelularni karcinom kože (BCK) je spororastući maligni epidermalni tumor. ovaj najčešći tumor u ljudi iako vrlo niskog metastatskog potencijala može biti visoko invazivan i značajno doprineti morbiditetu, ugroziti funkciju i estetiku regije, pa i sam život. Lečenje BCK ima za cilj: uklanjanje tumora, očuvanje zdravog tkiva i funkcije, optimalni kozmetski rezultat. Najčešći vid lečenja BCK je jednostavna hirurška ekscizija. Prema važećim preporukama BCK se ekscidiraju sa zaštitnim marginama od 5-10 mm. Određeni broju studija pokazuju direktno ili indirektno da je klinički određena margina vrlo slična realnoj. Ocena adekvatnosti kliničke procene u odnosu na histološku marginu tumora nije dovoljno ispitivana. Stopa kompletne ekscizije BCK (izlečenje) se ne povećava značajno sa povećanjem sigurnosne margine Cilj istraživanja je ustanovljavanje odnosa povezanosti između kliničke procene i mikroskopski utvrđene lateralne margine BCK na histološkom preparatu. Metodologija. U obradi uzorka od 45 ispitanika uzeti su ciljani anamnestički podaci, sproveden klinički pregled, uobičajena hirurške terapije i klasična patohistološka obrada uzoraka. U metodološkoj obradi 60 uzoraka tumora intraoperativno vrhom hirurškog skalpela celom cirkumferencijom kliničke margine tumora načinjen je zarez do nivoa papilarnog dermisa. Pre ekscizije dodata je zaštitna margina od 4-5 mm. Klasična patohistološka obrada je sprovedena kao i pregled preparata svetlosnim mikroskopom različitog uveličanja (h 40, h 100, h 200, h400). Merenje distance između načinjenog zareza, i histološke granice tumora vršena je uz pomoć milimetarskog okulara. Svi dobijeni podaci uneti su u zajedničku bazu podataka. Za statističku obradu podataka korišćen je program SPSS 21. Korišćene su metode metode deskriptivne statistike, univarijantne i multivasrijantne analize. Rezultati su prikazani tabelarno i grafički, a kompletan rad je obrađen u tekst procesoru MS Word. Rezultati. U 96,7% ekscidiranih BCK udaljenost zareza od patohistološke margine tumora je manja od 2,0 mm, dok je u dva tumora (3,3%) zarez na udaljenosti 2 i preko 2mm. U četvrtini uzorka (25%) zarez se nalazi u tumoru, a 75% uzorka zarez je načinjen van histološke granice tumora. Zaključak. Razlika između klinički obeležene i mikroskopom izmerene lateralne margine je u više od 95%, odnosno u 96,7% manja od 2 mm. U 88,4% slučajeva ova razlika u proceni je 1mm ili manje od 1mm. Postoji pozitivna korelacija između klinički procenjene i patohistološki određene lateralne margine BCK. Iako se pojedini prediktivni faktori koji utiču na lošiju kliničku procenu mogu izdvojiti, istraživanje nije pokazalo statističi značajne prediktivne faktore.</p> / <p>Introduction. Basal cell carcinoma of the skin (BCC) is a slow-growing malignant tumor of epidermis. This most frequent tumour in humans, with a low metastatical potential, can be highly invasive and add significantly to the morbidity rate; it can jeopardize the function and aesthetics of the region as well as one&#39;s life itself. Treatment of BCC aims to remove the tumor, preserve healthy tissue and function, and obtain optimal cosmetic result. Simple surgical excision is the most frequent therapeutic option. Current recommendations for surgical excision margins range from 5 to 10mm. A certain number of studies shows either directly or indirectly that the clinical margin is approximately similar to the hystology margin. Estimation of the clinical assesment in relation to the histological margine of tumor has not been sufficiently examined. Incresing the safety margins does not significantly increase the rate of completely excised BCC. Aim. The aim of the research is to establish the relationship between the clinical assessment and microscopically determined lateral margins of BCC in histopathological sample. Methods. In 45 patients, selected data from anamnesis have been taken, clinical examination has been conducted, as well as a regular surgical treatment, and a classical histopathological evaluation of samples. In 60 samples of the tumours intraoperatively, an circumferential incision at the clinical margin with the tip of surgical knife to the level of papillary dermis is made. Prior to the excision an additional safety margin is added. A standard histopathological processing, microscopic examination with various magnification range (40x, 100x, 200x, 400x) and the measurement of the distance between the incision and the histological margin of tumor was done with the milimetar graded ocular. All the data have entries in the common database. Statistical data processing was conducted by the statistical package SPSS 21. The following methods were used: descriptive statistics, univariate analysis and multivariate analysis. The results are given in tables and graphs and the entire study was processed by MS Word. Results. In 96,7% of the excided BCC the distance of the incision from the histopathological margin of the tumor is less than 2,0mm, while in the two tumors (3,3%) incision made was 2mm and over 2mm. In one quarter of the samples (25%) the incision is made in the tumor, and in 75% of them it is made outside the limits of its histological margin. Conclusion. The difference between the clinical estimation of lateral margin and histopathological margin of the tumor in 97% of the cases is less than 2mm. In 88,4% of the cases this difference amounts to 1mm or less than 1mm. There is a positive correlation between the clinically estimated and histopathological margins of the tumor. Although there are certain predictive factors that can influence somewhat worse clinical estimation, the research did not show statistically important predictive factors.</p>

Background. The development of non-invasive imaging techniques has been stimulated by the shortcomings of histopathology. Currently the only valid diagnostic technique in dermatology is skin biopsy which remains a painful, invasive intervention for the patient. Moreover, this approach is not always convenient for monitoring and follow-up of a skin disease. Optical imaging technologies could solve these shortcomings as they are fast, precise, repeatable and painless. There are four established non-invasive skin imaging techniques used in daily practice: dermoscopy, high-frequency ultrasound, reflectance confocal microscopy (RCM) and conventional optical coherence tomography (C-OCT). In imaging there is a trade-off between resolution and penetration depth. The former permits the visualization of cells, if the resolution is at least 3 µm. The latter enables the recognition of patterns and structures in deeper layers of the skin if the penetration depth is deeper than 150 µm. New non-invasive techniques using infrared light sources have been developed recently. The technique used in this work is a high-definition optical coherence tomography (HD-OCT).Objectives. The overall aims of this thesis were the feasibility of HD-OCT to visualize in/ex vivo, in real time and in 3-D the cellular and structural morphology of the skin, secondly the assessment of the capability of this technology to measure in vivo and real time the cutaneous optical properties, and finally the determination of the contribution of this technique to the non-invasive near-infrared imaging technologies. Five specific objectives have been established: i) could cells be observed in their 3-D microenvironment in normal and diseased skin, ii) could we describe morphologic features of cells and structures in normal and diseased skin (m_HD-OCT), iii) could these morphologic features be quantified by optical property analysis (o_HD-OCT), iv) was it possible to perform accurate thickness measurements in normal and diseased skin, and finally v) what was the diagnostic potential of this technique?Methodology. HD-OCT uses a combination of parallel time-domain interferometry, high power tungsten lamp (with Gaussian filter, very low lateral coherence and ultra-high bandwidth (1300 nm +/- 100 nm)), and last but not least, full field illumination with real time focus tracking. A constant homogeneous resolution of 3 µm resolution in all three dimensions is obtained up to a depth of 570 µm. Hence, the system is capable of capturing real time full 3-D images. Moreover, the in vivo assessment of optical properties of the skin is only applicable to OCT when operating in focus-tracking mode, which is the case for HD-OCT. The means to obtain answers to the five specific questions were the comparison of en face HD-OCT images with RCM and HD-OCT cross-sectional images with histopathology and C-OCT. Results. At least 160 line pares were observed by imaging a high resolution phantom with HD-OCT. This suggested a 3 µm lateral resolution. The presence of cells such as keratinocytes, melanocytes, inflammatory cells, fibroblasts and melanophages in their 3-D cutaneous microenvironment in vivo as well as ex vivo has been demonstrated .A qualitative description of structures and patterns in normal and diseased skin could be performed by HD-OCT. Clear structural changes of the epidermis, dermo-epidermal junction, papillary dermis and reticular dermis related to intrinsic skin ageing could be observed. Lobulated structures, surrounded by stretched stromal fibers and arborizing vessels, could be demonstrated in nodular basal cell carcinoma (BCC). The o_HD-OCT of normal and diseased skin could be assessed in vivo. This approach permitted the quantitative assessment of the OCT signal attenuation profiles of normal healthy skin, actinic keratosis (AK) and squamous cell carcinoma (SCC). Differences in signal attenuation profiles could be demonstrated between these three groups. These differences were also observed between BCC subtypes. The slope of the exponential attenuation of the signal in the upper part of the epidermis was very high in benign nevi. The more malignant the lesion the lower the slope. Thickness measurements of epidermis and papillary dermis could be performed by m_HD-OCT, based on a cross-sectional images and their corresponding en face image. More accurate measurements of epidermal and papillary dermal thickness could be performed based on the optical analysis of a skin volume by o_HD-OCT. The diagnostic potential of HD-OCT in comparison with dermoscopy, RCM and C-OCT could be assessed regarding i) melanoma, ii) BCC differentiation from BCC imitators and BCC sub-differentiation and iii) SCC differentiation from AK. A much higher diagnostic potential could be demonstrated for o_HD-OCT in comparison with m_HD-OCT concerning melanoma detection. The diagnostic potential of HD-OCT to discriminate BCC from clinical BCC imitators was moderate. However, HD-OCT seemed to have high potential in sub-differentiation of BCC subtypes: i) it seemed to be the best technique to include and exclude a superficial BCC, ii) the technique appeared to be the best approach to exclude nodular BCC, and iii) HD-OCT looked to be the best technique to include an infiltrative BCC. Finally, HD-OCT has proven to be a powerful method to discriminate AK from SCC.Conclusions. HD-OCT is able to capture real time 3-D imaging with a sufficiently high optical resolution and penetration depth to allow the visualization of cells in and ex vivo in their micro-architectural context. At the same time, HD-OCT permits the recognition of patterns and structures in a sufficiently large volume of skin (1.5 mm³). HD-OCT closes therefore the gap between RCM with a high resolution but low penetration depth and C-OCT with a low resolution but high penetration depth. Moreover, HD-OCT permits, in contrast to RCM and C-OCT, the real time in vivo analysis of optical properties of the skin. HD-OCT seems to be a promising tool for early diagnosis of melanoma, BCC sub-differentiation and differentiation between SCC and AK.Future perspectives. Multicenter validation studies are needed to determine the diagnostic performance of this promising new technology, especially in other clinical settings combining both morphological and optical property analysis. This combined analysis could be a valuable method not only for diagnosis, monitoring and therapeutic guidance of dermatologic diseases but it could also be helpful in the management of non-dermatologic conditions such as diabetic micro-angiopathy, infantile cystinosis or even osteoporosis. / Doctorat en Sciences médicales (Santé Publique) / info:eu-repo/semantics/nonPublished