DERMATOSKOPOWE CECHY KOMPONENTY NACZYNIOWEJ W RÓŻNYCH TYPACH MORFOLOGICZNYCH DYSPLAZII NASKÓRKA

Оlena О. Оshyvalova1,2

1 State Scientific Institution “Scientific and Practical Centre of Preventive and Clinical Medicine” of the State Administration, KYIV, UKRAINE

2 Shupyk National Medical Academy of Postgraduate Education, KYIV, UKRAINE

ABSTRACT

Introduction: Dermatologists of many foreign countries have been successfully using and developing dermatoscopy as a method of early diagnosis of skin tumors for three decades. It is believed that the vascular dermatoscopiccomponent is a promising criterion for the diagnosis of epidermal dysplasia of the skin and can be used for differential diagnosis.

The aim of the work was to study the features of the vascular dermatoscopic component in actinic keratosis (AK), non-invasive (squamous cell carcinoma in situ-SCCis) and invasive forms of squamous cell carcinoma (cSCC).

Material and methods: 68 dermatological images were studied, including 33 cases of AK, 22 cases of SCCis and 13 cases of cSCC of different localization. Pathology of the skin is confirmed by pathologic studies in 100% of cases. The dermatoscopic examination was performed by the Heine Delta 20 dermatoscope. The evaluation of the vascular component was performed using the DermaVisionPro software.

Results: In the analysis of dermatoscopic signs, the following vascular components were revealed: red pseudo-net (64.7%), strawberry pattern (36.8%), dotted vessels (26.5%), linear vessels (11.8%), polymorphic vessels (16.2%), blood vessels of the type of glomeruli (11.8%) and red globules (5.9%). The morphological type of dysplasia AK correlated with red pseudo-network (r =0.99) and strawberry pattern (r =0.92). The SCCis correlated with blood vessels of the type of glomeruli (r =0.82) and dotted vessels (r =0.75), the cSCC correlated with polymorphic (r =0.91) and linear (r =0.68) vessels.

Conclusions: The study confirms the existing opinion on the possible effective use of the vascular dermatoscopic component as a differential diagnostic criterion for non-invasive diagnosis of epidermal dysplasia of the skin. Typical combinations of vascular dermatoscopic components for morphological types of epidermal dysplasia – AK I-III, SCCis and cSCC were determined.

 

Wiad Lek 2018, 71, 2 cz. I, -268

 

INTRODUCTION

Dermatoscopy (epiluminescence microscopy) is a non-invasive method that allows the in vitro evaluation of microstructures of the epidermis and papillary dermis. Dermatologists have been successfully using and developing dermatoscopy as a method of early diagnosis of skin tumors. The main advantages of the method are non-invasiveness, high sensitivity and specificity, ease of use and the ability to keep information in an electronic database [1].

In2010 Zalaudek I.et al. suggested a three-step algorithm for dermoscopic evaluation of lesions with vascular involvement.Given that dermoscopy enables horizontal inspection of the skin, vessels that are located in parallel to the skin’s surface will appear as a line to the observer, while those located vertically to the skin’s surface will present as a dot or node [2]. It is known that there is a strong connection between the dominant vascular structure and tumor progression [3].

Six main morphological structures are widely identified, namely: coma-like, linear irregular, helical, hairpin-like, glomerular, and arborizing. In addition, there are three specific vascular patterns: crown vessels (located around a whitish core),strawberry vessels and milky red globules.Inrecentyearstherehave been reported the following vascular components: ring-shaped vessels, spermatozoa-like vessels and red globules (Figure 1) [1, 4].

Nevertheless, Kittler et al. (2008) have classified linear vessels into six subcategories: linear – flat (for linear – irregular vessels), linear – loop-like (for hairpin-like vessels), linear – curved (for comma-like vessels), linear – serpiginous (for linear – irregular, arborizing, crown vessels), linear – helical (for corkscrew vessels) and linear – coiled vessels (for glomerular vessels) [5].

Accordingtomorphologicalevaluation, structural vascular patterns play a crucial role in the diagnosis of non-pigmented lesions of the skin. In1990 arborizingvesselswereinitiallyfoundtobeusefulfordiagnosingbasal cell carcinoma of the skin [6]. Hairpin-like vessels generally appear in nonmelanocytic tumours, such as squamous cell carcinoma, seborrheic keratosis and keratoacanthoma [7].Comma-like vessels are a differential dermoscopic feature in dermal nevus, with a positive predictive value of 94%[8]. Corkscrew vessels were described in amelanotic melanoma of more than 2 mm thick [9, 10] and in 31% of cases of basal cell carcinoma [11, 12].Linear-tortuous vessels can appear in Merkel cell carcinoma [13], amelanotic melanoma [10], dermatofibroma [14]. Crownvesselsshow up in sebaceous hyperplasiaand appear in sebaceous glandsadenoma [15] andnevus sebaceous of Jadassohn [16].

Epidermal dysplasia is characterized by dotted, glomerular and polymorphic vessels,red globules and strawberry pattern (Figure 1) [17, 18].Dotted vessels correspond to the tips of short, vertically arranged capillaries in lesions of smaller diameters and appear in dermoscopy as very small red dots with diameters of 0.01-0.02 mm. Such vessels may appear in keratinized AK, SCCisand сSCC[19, 20].

Polymorphic vessels involve a combination of two or more different vascular patterns. The most frequent combination comprises linear-irregular vessels and dotted vessels, which is quite specific to skin carcinomas[4,21].

Glomerular vessels appear as balls of wool which resemble renal glomeruli.Zalaudek et al. observed that glomerular vessels appeared in 100% of non-pigmented SCCis patients and 80% of pigmented SCCis patients [22, 23].

Red globules are round or oval, red structures that are larger than dotted vessels. Pan Y. et al. detected red globules in 32% of patients with SCCis [24].

Strawberry pattern is a formation of erythema that creates pseudo-networks of red-pink colour around hair follicles filled with keratin. Zalaudek et al. observed this pattern in over 90% of patients with AK, for this reason strawberry pattern is considered a pathognomonic dermatoscopic sign of AK [20].

At present it is believed that the vascular dermatoscopiccomponent is a promising criterion for the diagnosis of epidermal dysplasia of the skin and can be used for differential diagnosis of actinic keratosis, noninvasive and invasive squamous cell carcinoma of the skin.

 

THE AIM

The aim of the research was to study the features of the vascular dermatoscopic component in various morphological types of epidermal dysplasia of the skin – AK I-III, SCCis and cSCC.

MATERIALS AND METHODS

We have studied 68 dermatological images of epidermal dysplasia in patients undergoing intensive monitoring by dermatologists of the State Scientific Institution “Research and Practical Centre of Preventive and Clinical Medicine” of the State Administration. Pathology of the skin is confirmed by pathologic studies in 100% of cases. The dermatoscopic examination was performed by the Heine Delta 20 dermatoscope with a SLR photo adapter. The evaluation of the vascular component was performed using the DermaVisionPro software.

The severity of dysplasia in case of AK was determined according to the classification suggested by C. Cockerell and J. Wharton (KIN I – keratinocyte intraepidermalneoplasia mild, KIN II – keratinocyte intraepidermal neoplasia moderate,KIN III – keratinocyte intraepidermal neoplasia severe) [25].

RESULTS AND DISCUSSION

Among68 examinedpatientswithepidermaldysplasiaoftheskin, thereweredetected11 patientswithАК KIN І (16.2%), 10 patients with АК KIN ІІ (14.7%), 12 patients with АКKIN ІІІ (17.6%), 22patients with SCCis (32.4%)and 13 patients with cSCC (19.1%).In the analysis of dermatoscopic signs, the following vascular components were revealed: red pseudo-net (64.7%), strawberry pattern (36.8%), dotted vessels (26.5%), linear vessels (11.8%), polymorphic vessels (16.2%), blood vessels of the type of glomeruli (11.8%) and red globules (5.9%).

The distribution of vascular dermatoscopic component with the above pathology is presented in Figure 2.

InpatientswithAК KIN І and АК KIN ІІ therewasmainlyrevealedredpseudo-netorstrawberrypatternalmostin 100% ofcases. The most varied dermatoscopic pattern was common with patients with AK and KIN III and was represented by 6 vascular components in various combinations: red pseudo-net (66.7%), strawberry pattern (83.3%), dotted (41.7%) and linear vessels (33.3%), polymorphic vessels (25%) and red globules (8.3%). In patients with SCCis there was detected a combination of 7 vascular components, namely red pseudo-net (27.3%), strawberry pattern (31.8%), dotted vessels (50%), vessels of the type of glomeruli (36.4%) and red globules (13.6%), linear (9.1%) and polymorphic (18.2%) vessels. In patients with cSCC there were revealed 4 vascular components in combinations, including red pseudo-net (15.4%), strawberry pattern (7.7%), dotted vessels (15.4%), linear (53.8%) and polymorphic (69.2%) vessels.

In summary it should be noted that in our study the morphological type of dysplasia AK KIN І correlated with vascular dermatoscopic component –red pseudo-network (r=0.99),АК KIN ІІ – strawberry pattern (r=0.92) and red pseudo-net (r=0.81), АК KIN ІІІ –red pseudo-net (r=0.74), strawberry pattern (r=0.83) and dotted vessels (r=0.72) . The morphological type of dysplasia of SCCis correlated with blood vessels of the type of glomeruli (r=0.82) and dotted vessels (r=0.75). The pathomorphological type of dysplasia cSCC correlated with polymorphic (r=0.91) and linear (r=0.68) vessels (Table І).

CONCLUSIONS

The study confirms the existing opinion on the possible effective use of the vascular dermatoscopic component as a differential diagnostic criterion for non-invasive diagnosis of epidermal dysplasia of the skin.

ForАК KIN І,atypicalvasculardermatoscopicsign can be the presence of red pseudo-net, forАК KIN ІІ – strawberry pattern, for АК KIN ІІІ – a combination of strawberry pattern and dotted vessels or red pseudo-net. For SCCis, a combination of vessels of the type of glomeruliand dotted vessels is typical. In case of cSCC there prevails a combination of vasculardermatoscopicsigns in the form of polymorphic and linear vessels.

Thepresentedmaterialisrecommended to be used in practice of dermatologists and oncologists during differential diagnostic analysis of epidermal dysplasia of the skin.

REFERENCES

1. Bugatti L., Filosa G., De Angelis R. The specific dermoscopical criteria of Bowen’s disease. J Eur Acad Dermatol Venereol. 2007,21:700–701.

2. Vázquez-López F., Kreusch J., Marghoob A.A. Dermoscopic semiology: further insights into vascular features by screening a large spectrum of nontumoral skin lesions. Br J Dermatol. 2004, 150:226-31.

3. Zalaudek I., Kreusch J., Giacomel J. et al.How to diagnose nonpigmented skin tumors: A review of vascular structures seen with dermoscopy. Part I. Melanocytic skin tumors. J Am Acad Dermatol. 2010, 63:361-74.

4. Zalaudek I., Giacomel J., Argenziano G. et al. Dermoscopy of facial nonpigmented actinic keratosis. Br J Dermatol. 2006, 155:951-6.

5. Menzies S.W., Kreusch J., Byth K. et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol. 2008, 144:1120-7.

6. Wolf I.H. Dermoscopic diagnosis of vascular lesions. Clin Dermatol. 2002, 20:273-5.

7. Argenziano G., Zalaudek I., Corona R.et al. Vascular structures in skin tumors. A dermoscopy study. Arch Dermatol. 2004, 140:1485-9.

8. Zalaudek I., Argenziano G., Leinweber B. et al. Dermoscopy of Bowen’s disease. Br J Dermatol. 2004, 150:1112-6.

9. Kittler H., Riedl E., Rosendahl C., Cameron A. Dermatoscopy of unpigmented lesions of the skin: a new classification of vessel morphology based on pattern analysis. Dermatopathology: Practical e Conceptual. 2008. [cited 2010 Aug 02]. Available from: http://www.derm101.com.

10. Micantonio T., Gulia A., Altobelli E. et al. Vascular patterns in basal cell carcinoma. J Eur Acad Dermatol Venereol. 2011, 25:358-61.

11. Trigoni A., Lazaridou E., Apalla Z.et al. Dermoscopic features in the diagnosis of different types of basal cell carcinoma: a prospective analysis. Hippokratia. 2012, 16:29-34.

12. Agero A.L., Taliercio S., Dusza S.W. et al. Conventional and Polarized Dermoscopy Features of Dermatofibroma. Arch Dermatol. 2006, 142:1431-7.

13. Zalaudek I., Leinweber B., Johr R. Nevi with particular pigmentation: black, pink, and white nevus. In: Soyer HP, Argenziano G, Hofmann-Wellenhof R, Johr R, editors. Color atlas of melanocytic lesions of the skin. Berlin-Heidelberg: Springer Verlag; 2007, p. 142-6.

14. Zalaudek I., Argenziano G., Oliviero M., Rabinovitz H. Dermoscopy of nonpigmented skin tumors. In: Thiers BH, Lang PG Jr, editors. Year book of dermatology and dermatologic surgery 2007. Philadelphia: Elsevier Mosby; 2007, p. 23-38.

15. Felder S., Rabinovitz H., Oliviero M., Kopf A. Dermoscopic differentiation of a superficial basal cell carcinoma and squamous cell carcinoma in situ. Dermatol Surg. 2006, 32:423-5.

16. Cavicchini S., Tourlaki A., Bottini S. Dermoscopic vascular patterns in nodular “pure” amelanotic melanoma. Arch Dermatol. 2007, 143:556.

17. AyhanЕ.  , UcmakD.  , Akkurt Z.M.  Vascular structures in dermoscopy.An. Bras. Dermatol. 2015, 90(4):545-53.

18. Zaballos P., Ara M., Puig S., Malvehy J. Dermoscopy of sebaceous hyperplasia. Arch Dermatol. 2005, 141:808.

19. Zalaudek I., Argenziano G., Di Stefani A.et al. Dermoscopy in general dermatology. Dermatology. 2006, 212:7-18.

20. Cockerell C. J., Wharton J. R. New histopathological classification of actinic keratosis (incipient intraepidermal squamous cell carcinoma). J. Drugs Dermatol. 2005, 4: 462-7.

21. Kim N.H., Zell D.S., Kolm I., Oliviero M., Rabinovitz H.S. The dermoscopic differential diagnosis of yellow lobularlike structures. Arch Dermatol. 2008, 144:962.

22. Zalaudek I., Di Stefani A., Argenziano G. The specific dermoscopic criteria of Bowen’s disease. J Eur Acad Dermatol Venereol. 2006, 20:361-2.

23. Pan Y., Chamberlain A.J., Bailey M. et al. Dermatoscopy aids in the diagnosis of the solitary red scaly patch or plaque-features distinguishing superficial basal cell carcinoma, intraepidermal carcinoma, and psoriasis. J Am Acad Dermatol. 2008, 59:268-74.

24. Harting M.S., Ludgate M.W., Fullen D.R., Johnson T.M., Bichakjian C.K. Dermatoscopic vascular patterns in cutaneous Merkel cell carcinoma. J Am Acad Dermatol. 2012, 66:923-7.

25. Zalaudek I., Kreusch J., Giacomel J. et al. How to diagnose nonpigmented skin tumors: A review of vascular structures seen with dermoscopy. Part II. Nonmelanocytic skin tumors. J Am Acad Dermatol. 2010, 63:377-86.

 

This work is a fragment of research “Development of model of multifactor prevention and healthcare quality management of medical care in some chronic infectious diseases of attached population”, No. of state registration 0114U002118.

ADDRESS FOR CORRESPONDENCE

Olena O. Oshyvalova

5, Verhnyaya Street, Kyiv 04012, Ukraine.

tel: +38 (044) 254 64 35 ; +38 (050) 63 47 403

e-mailoshivalovaea@gmail.com

Received: 20.02.2018

Accepted: 10.04.2018

Figure1. Schematic representation of vascular dermatoscopic structures

(Ayhan Е.  , UcmakD.  , Akkurt Z.M., 2015): arborizingvessels (А), hairpin-like (В),
linear (С), polymorphic (D), comma-like (Е), dotted (F), glomerular (G),
corkscrew (Н), crown (J), strawberrypattern (K), milkyredglobules (L), redglobules (M), twistedredloops (N), spermatozoa-likevessels (O).

Figure 2. The distribution of vascular dermatoscopic signs among examined patient with AK, SCCis and cSCC.

Table I. Correlation relationship between vascular dermatoscopic signsand morphological type of epidermal dysplasia of the skin

Vascular dermatoscopic signs

Rank Correlation Coefficient to various morphological types of epidermal dysplasia of the skin

АК

SCCis

cSCC

KIN І

KIN ІІ

KIN ІІІ

Red pseudo-net

0.99

0.81

0.74

0.23

0.31

Strawberry pattern

0.42

0.92

0.83

0.22

Dotted vessels

0.12

0.32

0.72

0.75

0.4

Linear vessels

0.13

0.18

0.2

0.33

0.68

Polymorphic vessels

0.21

0.41

0.91

Vessels of the type of glomeruli

0.82

Red globules

0.14

0.08