| Skin tumors are one of the most common tumors in the body.Common skin malignancy includes Bowen’s disease,BCC(BCC),squamous cell carcinoma(SCC),extra mammary Paget’s disease and malignant melanoma.In recent years,the morbidity and mortality of skin malignancies have increased in China,with the highest incidence of BCC and followed by SCC[1].There are various treatments of skin malignancies,including surgical,laser,electrocautery,cryotherapy,radiotherapy,photodynamic therapy,etc.But the main method used clinically is the surgery.With the improvement of people’s living quality,clinicians are facing new challenges.More and more patients not only require to be cured,but also want to get better appearance as much as possible.At present,only Mohs micrographic surgery can cure the whole tumor while retaining the normal skin to the maximum.However,the prevalence of MOHS surgery in China is low due to many limits as following:(1)to need physicians with specialized pathological knowledge,(2)to need expensive instruments such as cry section machine,(3)long time,heavy labor and low income,(4)to need high cost which patients would not like to afford.Therefore,researchers have begun to focus on the field of imaging to determine the edge of the tumor.Many literature shows that photodynamic,reflectance confocal microscopy,dermoscopy,skin B-ultrasound,and skin MRI have certain auxiliary effects on the determination of tumor margins.These examinations have their own advantages and disadvantages.For example,photodynamics can clearly define the tumor margin but photodynamics has a long incubation time before the operation,and the margins determined by photodynamics aren’t clear.Photodynamics are expensive,and patients with photosensitivity cannot use it.Reflectance confocal microscopy is quick and convenient but the image only has poor resolution,low penetration depth and no color.Skin ultrasound and MRI have played important role in the evaluation of tumors,but the accuracy of the margin is not high due to the limited resolution of the machine.Compared with the previous examinations,the dermoscopy is undoubtedly simpler,safer,more affordable,and requires minimal training for doctors.It can not only assist in the diagnosis,but also help defining the margins of skin tumors.In this paper,dermoscopy was used to define the skin tumor boundary and the surgical margin.Then the pathological analysis of the margin tissue was performed to evaluate the significance of the dermoscopy in determining the surgical margin of the tumor.The First Part:Dermoscopy in assisting on defining surgical margins of BCCObjectiveThe first part aims to observe the features of different types of BCC by dermatoscopy,and compare the result which is better in defining tumor boundary between dermatoscopy and visual observation.Then the optimal distance of the surgical margins will be determined through the pathological analysis of the margin tissue.MethodsA total of 42 patients with BCC who visited the Department of Dermatology,Jiangsu Province Hospital from January 1,2016 to March 1,2018 were selected as research objects.All 42 patients were primary BCCs,of whom 15(35.7%)were females and 27(64.3%)were males.The age ranged from 42 to 84 years and the average were 64.4 years.Before the operation,the tumor boundary was visually observed and then using a dermoscopy.The observed BCC classic patterns were recorded,and the boundaries of the tumor were marked.An incision was made 0.5 cm outwards using the boundary of the dermoscopy mark as a reference.The laterally enlarged skin was selected from the four "3,6,9,12" o’clock direction and submitted to a uniform method of histological examination with serial parallel sections at 2-mm intervals.Results1.Among classical dermoscopy pattern of BCC,the arborizing vessels have the highest frequency up to 85.7%.Ulceration,multiple blue–grey globules and massive Blue–grey ovoid nests have similar frequency of occurrence with 47.7%、42.9%、40.0% respectively.Maple leaf-like areas are few,accounting for only 14.3% of the total.No Spoke-wheel areas are found.The most common types of nodular BCC are vessels and ulceration.For pigmental BCC,the most types are vessels and blue–grey globules.Maple leaf-like areas are the most common type of superficial BCC.2.Among the 42 patients,28 borders are consistent demarcated by both the naked eye and dermoscopy,which accounted for 66.7% of the total.The other 14 inconsistencies accounts for 33.3% of the total.3.When the margin is 2 mm beyond the edge of BCC identified by dermoscopy,the cleanly removal rate of tumor cells is 155/168(92.3%),and only 13 cases are not cleanly removal accounted for 7.7%.The cleanly removal rate of patients is 34/ 42(81.0%).The other 8 cases accounts for 19%.When the margin is 4 mm outside the edge of BCC identified by dermoscopy,all specimens show no tumor remnants,and the rate of excision is up to 100%.No patient has relapsed.4.The most differences between the naked eye and dermoscopy is pigmented BCC,and the difference rate is 8/18(44.4%).The differences between nodular and superficial BCCs are lower,5/19(26.3%)and 1/5(20%),respectively.When comparing the slicing positive rate at 2 mm,the superficial positive rate is the lowest,the pigmented type is 2/18(11.1%),and the nodular ulcer type is 6/19(31.6%).Conclusion1.Arborizing vessels are the most common in the classic dermoscopy pattern of BCC.Blood vessels and ulceration are the most common types of nodular ulcerative type BCC.Branch-like blood vessels and blue-gray globules are the most common types of pigmentation.Maple leaf-like areas are the most common of superficial types.2.The observation of the boundary of the tumor by the dermoscopy is better than naked eye,especially the pigmented BCC.However,the dermoscopy has no obvious advantage for the nodular BCC.3.The tumor can be basically completely removed when the margin expanded to 4mm beyond BCC.The Second Part:Dermoscopy in assisting on defining surgical margins of SCCObjectivesThe second part aims to observe the features of SCC with different degrees of differentiation by dermatoscopy,and compare the result which is better in defining tumor boundary between dermatoscopy and visual observation.Then the optimal distance of the surgical margins will be determined through the pathological analysis of the margin tissue.MethodsA total of 10 patients with squamous cell carcinoma who visited the Department of Dermatology,Jiangsu Province Hospital from January 1,2016 to March 1,2018 were selected as research objects.All 10 patients were primary squamous cell carcinomas,of whom 3(10.0%)were females and 7(70.0%)were males.The age ranged from 56 to 88 years and the average was 72.5 years.Before the operation,the tumor boundary was defined by visually observation and dermoscopy.An incision was made 0.8 cm outwards using the boundary of the dermoscopy mark as a reference.The laterally enlarged skin was selected from the four "3,6,9,12" o’clock direction.From the margin of the incision,the pathological analysis after sectioning was performed at intervals of 4 mm to determine the residual condition of the tumor.Results1.All 10 patients are well-differentiated SCC.There are 7 cases(70.0%)with yellow-white keratin in the center.7 cases(70.0%)are surrounded by elongated telangiectasias,which appear as irregularly linear and coiled.2 patients have pearl-like structure(20.0%).2.Among the 10 patients,3 patients’ borders were consistent demarcated by the naked eye and dermoscopy,which accounted for 30.0% of the total.The other 7 patients’ borders inconsistencies accounted for 70.0% of the total.3.When the margin was 4 mm beyond the edge of SCC identified by dermoscopy,the rate of curing tumor cells was 100%.The patients are still being followed.Conclusions1.The dermoscopic appearances of well-differentiated SCC are yellow-white keratin in the center,elongated telangiectasias which appear as irregularly linear and coiled and Pearl-like structure.2.The observation of the boundary of the tumor by the dermoscopy is better than naked eye. |
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