1. SIAscope Training Course Micro-architecture of skin lesions

2. SIAscope training course aims After this course you will be able to discuss: –Common skin lesions, and their histology –Methods of melanoma diagnosis and their relative merits

3. Programme Structure of the skin Common lesions Premalignant lesions Melanoma

4. Boundaries Basic structure applicable to SIAgraphs Melanoma Conditions that can be mistaken for melanoma

5. Motivation 18% of melanomas are misdiagnosed in first clinical episode – BJD 1999 Difficulties of diagnosis –Skin is a complex organ –Many components –Components may have strong visual resemblance to each other –Different conditions can look the same

6. Structure of the skin Epidermis Dermis

7. Epidermis Dermal papillae Rete ridges

8. 1.2 Histology of the skin Epidermis – 5 layers –Stratum corneum –Stratum granulosum Dermis –Papillary –Reticular

9. Epidermis Stratum Corneum (Hornlike Layer) –20-30 layers of dead, anucleated cells –outer cells are constantly shed Stratum Lucidum (Clear Layer) –only seen in thick skin –2-3 layers of dead, anucleate cells Stratum Granulosum (Granular Layer) –3-5 layers of granular, flattened cells Stratum Spinosum (Spiny Layer, Prickly Layer) –several layers of polygonal-shaped cells Stratum Basale (Basal Layer) –single layer of columnar/cuboidal cells resting on basement membrane

10. Dermis + Beyond Dermis –Separates into papillary and reticular dermis –Dense irregular connective tissue –Collagen –Contains nerve endings, hair follicles, glands, capillaries –Dermal papillae (projections of dermal tissue into the epidermis) interlock with rete ridges Hypodermis or Superficial Fascia –Subcutaneous tissue underneath dermis –Stores fat and helps anchor skin

11. Common lesions May appear similar to melanoma –But benign Appearance and history important –Junctional, Compound, Intradermal naevi –Blue, Spindle-cell naevi –Seborrheic Keratosis –Pyogenic Granuloma –Haemangioma

12. Histology of skin naevi Normal skin

13. Histology of skin lesions Freckles –Seen on many people Junctional naevus –Common “mole”

14. Compound naevus Acquired between 6 months and 35 years May be raised Brown

15. Compound naevus histology Nests of melanocytes at rete tips Nests of melanocytes in dermis producing less melanin

16. Compound naevus

17. Blue Naevus Usually begin early in life May appear similar to nodular melanoma Rounded nest of melanocytes in the dermis Blue.

18. Blue Naevus histology

19. Blue Naevus

20. Spitz / Spindle Cell Naevus Occurs mainly in children Smooth, round, slightly scaling pink nodule Very difficult to diagnose –Resemble melanoma even in histology.

21. Spitz / Spindle Cell Naevus

22. Seborrhoeic Keratosis Acquired in middle and later life Slow-growing Scaling / “stuck-on” appearance

23. Seborrhoeic Keratosis - Histology

24. Seborrhoeic Keratosis

25. Pyogenic Granuloma Proliferation of blood vessels

26. Pyogenic granuloma

27. Haemangioma Several kinds Cherry angioma can be mistaken for melanoma –2 to 5mm –Red to purple in colour –Usually on the trunk, can be multiple

28. Haemangioma Histology Lacunes of blood

29. Cherry Angioma

30. Premalignant Lentigo maligna Dysplastic naevus

31. Dysplastic Naevus – warning! With or without dermal nests Capillary proliferation Increase in Collagen in dermis

32. Dysplastic Naevus – warning!

33. Lentigo Maligna Precursor to lentigo maligna melanoma Large, cosmetically sensitive areas Excision undesirable in frail/elderly patients unless lesion changes to lentigo maligna melanoma

34. Lentigo Maligna Punch biopsies sometimes used to confirm diagnosis Disfiguring, inaccurate Dermal melanin SIAgraph indicates change to lentigo maligna melanoma

35. Lentigo Maligna

36. Histology of skin lesions Melanoma – stages –Radial Growth Phase (RGP) –Vertical Growth Phase (VGP)

37. Histology of Melanoma

38. Melanoma Superficial spreading melanoma (SSM) Nodular malignant melanoma (NMM) Amelanotic melanoma

39. Superficial Spreading Melanoma Radial Growth Phase Microinvasion

40. SSM - Histology

41. Superficial Spreading melanoma

42. NMM VGP Larger areas of dermal melanin

43. 1.2 Histology of skin lesions

44. Nodular melanoma

45. Amelanotic Melanoma Less melanin Very rare SIAscope can diagnose in theory –No amelanotic melanomas in studies as yet

46. Amelanotic melanoma

47. Melanoma treatment Excision to fascia Margin based on thickness of tumour –Up to 3cm for thick lesions Sentinel node biopsy(?) Chemotherapy, Radiation, Immunotherapy (interferon), Medical trials.

48. Melanoma Prognosis Breslow thickness –Stratum granulosum to bottom of tumour in mm Clark’s level –1:in situ (epidermis) –2:upper papillary dermis –3:full thickness of papillary dermis –4:reticular dermis –5:subcutaneous fat Several others

49. Breslow thickness

50. End of presentation Many different conditions may appear clinically similar to melanoma Diagnosis is difficult –More in the next presentation