On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.5 Rio de Janeiro Sept./Oct. 2009
Marcus MaiaI; Rute Facchini LellisII; Alessandra Cristine MartaIII
IPh.D., Head/ Joint Professor, Dermatology
Clinic, Santa Casa de São Paulo São Paulo (SP), Brazil
IIPathologist Assistant, Department of Clinical Pathology, Santa Casa de Misericórdia de São Paulo São Paulo (SP), Brazil
IIISpecialist in Dermatology, Brazilian Society of Dermatology Physician, Dermatology Clinic, Santa Casa de São Paulo São Paulo (SP), Brazil
Clinicopathologic correlation is essential for diagnostic accuracy. Even though interdependent, dermatology and dermatopathology have become apart. In order to minimize this distance, we have performed ex vivo dermoscopic examinations. We performed comparative in vivo and ex vivo dermoscopy study followed by histopathological mapping. We observed that ex vivo dermoscopy identified the same structures visualized by the in vivo one, but with significant change of colors.
Keywords: Dermoscopy; Melanoma; Pathology
Scope et al 1 have recently discussed the conditions that involve from the biopsy performed by the dermatologist up to final diagnosis by the dermopathologist. They stated that there are few dermatologists that examine patients slides, and on the other hand, dermatopathologists rarely see the clinical side of cases. Moreover, biopsy specimen is normally prepared by technicians, leaving to the pathologist very little from the original lesion. These authors believe that the clinical-pathology distance may lead to diagnostic disagreement, especially in skin cancer.
To reduce this disagreement, they proposed that the dermatologist could send, together with the surgical material, a clinical and dermatoscopic picture of the melanocytic lesion marked with the points of concern to the clinician. As dermatoscopy is of great value to clinicians 2, which could be shared with the pathologist by the ex vivo dermatoscopic analysis of the surgical specimen.
We decided to explore and expand this idea of ex vivo dermatoscopy as a supporting method to histopathology with the following objectives:
1. to train dermatopathologists to get familiar with dermatoscopic language;
2. to assess ex vivo dermatoscopy with contact dermatoscope reducing the shrinkage of the surgical specimen, as observed in the study by Scope et al 1 who used polarized light dermatoscope without contact; 3
3. to assess whether in vivo and ex vivo dermatoscopy can be compared;
4. to assess whether the pathologist is proficient in the clinicians language;
5. to mark the section points of the specimen for precise comparison between the histopathology slides and dermatoscopy;
6. to assess feasibility of this procedure as a routine;
7. to use comparative precision between in vivo, ex vivo and pathology as the element to better understand dermatoscopy.
The pathologist participated in the theoretical and practical course on dermatoscopy before the study started.
We took a clinical and dermatoscopic photography before surgery. Dermatoscopic in vivo images were obtained using a contact dermatoscope (alcohol gel) coupled to a digital camera (Sony Cyber-shot DSC-W70). After that, the surgical specimen was submitted to 12 hours of fixation in formol.
The 0.8cm lesion was located on the back of a man aged 75 years. Clinically, the hypothesis was melanoma. Dermatoscopy (Figure 1) showed asymmetry in the morphology and color. In details, there was a regular network over the largest area of the lesion, but it was possible to identify sites with sudden end, strias, cells outside the network and thick and gray network. Despite the fact that these characteristics reinforced the hypothesis of melanoma 4, because they were focal, we may assume that a typical affection could exclude the diagnosis. Based on these concerns, we sent the surgical and clinical dermatoscopic material to the pathologist.
The lesion was excised with 2mm margins and fixed in formol. Twelve hours later, the pathologist placed it on blue tissue, examined it with contact dermatoscope and performed the dermatoscopy photo with a graded ruler that determined exactly the areas contained in the section space (Figure 2). The specimen, after marking the section sites, was photographed with the dermatoscope. The sections were made cranium-caudally with 1mm intervals (Figure 2). The obtained slides were examined knowing exactly the site corresponding to the dermatoscopy.
The in vivo dermatoscopic examination allowed the identification of the same structures visualized in the in vivo dermatoscopy, however, there were significant color changes: brown areas became gray and grey areas became blue (Figure 1).
The clinical pathology examination revealed dysplastic junctional nevus with marked atypia. The areas of greater concern by dermatoscopy coincided with those of greater cytoarchitecture disarrangement (Figure 1). The abnormalities found were not enough to diagnose melanoma.
Ex vivo exam allows the exact determination of section sites and to make correlation with the pathology 5,6,7. The increase in diagnostic acuity that dermatoscopy brought to the clinician can now be transferred to the pathologist.
One limitation of the exam is the relative loss of vascular structures. When they are evident in vivo, it may hinder the correlation with ex vivo analysis.
In addition, in some cases of melanoma, the pathologist, guided by dermatoscopy, may look for the area with the greatest thickness.
This is a preliminary discussion but a more detailed study will be carried out by our group to assess the academic feasibility of the method and above all its applicability in the pathologist routine. Ex vivo examination, to be understood, should be limited to pigmented suspected lesions, should aggregate specificity and sensitivity to the diagnosis of melanoma and should not negatively impact the financial aspect.
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Conflict of interest: None
Financial funding: None
How to cite this article: Maia M, Lellis RF, Marta AC. Dermatoscopia ex vivo: avaliação sincrônica entre o dermatologista e o dermatopatologista de lesões melanocíticas Estudo prévio. An Bras Dermatol. 2009;84(5):553-5.
Conflict of interest: None