Ac a De m Vene eol 95
INVESTIGATIVE REPORT
Ac a De m Vene eol 2015; 95: 549–552
© 2015 The Au ho s. doi: 10.2340/00015555-2010
Jou nal Compila ion © 2015 Ac a De ma o-Vene eologica. ISSN 0001-5555
Len igo maligna (LM) is an in si u o m o melanoma
which can p og ess in o in asi e len igo maligna mela-
noma (LMM). Va ia ions in he pigmen a ion and hus
isibili y o he umou make assessmen o lesion bo -
de s challenging. We es ed hype spec al imaging sys-
em (HIS) in in i o p eope a i e delinea ion o LM and
LMM ma gins. We compa ed lesion ma gins delinea ed
by HIS wi h hose es ima ed clinically, and con i med
his ologically. A o al o 14 LMs and 5 LMMs in 19 pa-
ien s we e included. HIS analysis ma ched he his o-
pa hological analysis in 18/19 (94.7%) cases while in 1/19
(5.3%) cases HIS showed lesion ex ension no con i med
by his opa hology ( alse posi i es). Compa ed o clinical
examina ion, HIS de ined lesion bo de s mo e accu a-
ely in 10/19 (52.6%) o cases (wide , n = 7 o smalle ,
n = 3) while in 8/19 (42.1%) cases lesion bo de s we e he
same as delinea ed clinically as con i med his ologically.
Thus, HIS is use ul o he de ec ion o subclinical LM/
LMM bo de s. Key wo ds: len igo maligna; len igo ma-
ligna melanoma; umou ma gin assessmen ; hype spec-
al imaging.
Accep ed No 12, 2014; Epub ahead o p in No 14, 2014
Ac a De m Vene eol 2015; 95: 549–552.
Noo a Nei aanmäki-Pe u, MD, Depa men o De -
ma ology and Alle gology, Helsinki Uni e si y Cen al
Hospi al, Box 160 Meilahden ie 2, FIN-00029 Helsinki,
Finland. E-mail: [email p o ec ed]
Len igo maligna (LM) is an in si u o m o melanoma
whe e he neoplas ic cells a e con ined o he epide mis
and lack de mal in asion. LM is he mos p e alen in
si u sub ype (79–83%) o melanoma. I un ea ed LM
may p og ess in o in asi e len igo maligna melanoma
(LMM). The incidence o LM and LMM is cons an ly
inc easing o e he o he melanoma sub ypes (1, 2). Ea ly
and e icien su gical emo al is he me hod o choice in
he ea men o LM and LMM.
Assessmen o he bo de s o LM and LMM is chal-
lenging bo h clinically and his ologically. Lesions can
ex end se e al cm beyond he clinically es ima ed
ma gins (3). In clinical p ac ice Wood’s ligh (320–400
nm) is widely used o help he delinea ion o he umou
ma gins. Melanin abso bs mos o he UV adia ion skin
is exposed o. Thus, Wood’s ligh inc eases he con as
be ween heal hy skin and a eas p esen ing e en mino
inc eases in epide mal melanin pigmen a ion (4). How-
e e , he pigmen con en may no be inc eased in all
a eas o LM g ow h.
We ha e ea lie shown ha a no el hype spec al ima-
ging sys em (HIS) e icien ly de ec s a eas o subclinical
skin ield cance isa ion (5). Hype spec al imaging
combines adi ional spec oscopy and imaging echni-
ques by p oducing 3 dimensional da a cubes, e e ed
as hype spec al images, whe e in addi ion o spa ial
(x, y loca ion) in o ma ion, image con ains a spec al
g aph (z in ensi y) o each pixel (6). Thus, hype spec-
al image consis s o a s ack o images, o which each
image is aken a di e en na ow wa eleng h and each
pixel in he image has i s own spec al signa u e (Fig 1).
Delinea ing Ma gins o Len igo Maligna Using a Hype spec al
Imaging Sys em
Noo a NEITTAANMÄKI-PERTTU1,2, Ma i GRÖNROOS2, Leila JESKANEN1, Ilkka PÖLÖNEN3, Annama i RANKI1, Olli SAKSELA1
and E na SNELLMAN2,4
Depa men o De ma ology and Alle gology, 1Helsinki Uni e si y Cen al Hospi al, Helsinki and 2Päijä -Häme Cen al Hospi al, Lah i, 3Depa men o
Ma hema ical In o ma ion Technology, Uni e si y o Jy äskylä, Jy äskylä, and 4Depa men o De ma ology, Tampe e Uni e si y and Tampe e Uni e si y
Hospi al, Tampe e, Finland
Fig. 1. Hype spec al imaging p ocess and da a analysis. Hype spec al image (cube) consis s o o e lapping images, o which each is aken a di e en
wa eleng h. Each pixel in he hype spec al image has i s own spec al signa u e. Ma hema ical algo i hms (VCA, FVA) a e used o sepa a e he spec a
(endmembe s) o benign and malignan issue. The abundance images ep esen he a eas o lesional and heal hy skin.
550 N. Nei aanmäki-Pe u e al.
Di e en biological issues can be iden i ied om hei
unique spec al signa u es e lec ing hei biochemical
cha ac e is ics (6–8). This pilo s udy aimed o es he
easibili y o he HIS in delinea ion o he ma gins o
LM and LMM p eope a i ely in o de o a oid he need
o e-excisions.
MATERIALS AND METHODS
Pa ien s
The s udy p o ocol ollowed he Decla a ion o Helsinki and
was app o ed by he local e hics commi ee. All olun ee ing
pa ien s p o ided hei w i en in o med consen . The pa ien s
we e ec ui ed om hose emi ed o he Depa men o De -
ma ology o hei suspec ed LMs.
Nine een pa ien s, 7 women and 12 men, wi h clinically
suspec LM o LMM loca ed on hei aces o scalps we e
included in he s udy. The pa ien s’ mean age was 77.9 ( ange
67–97 yea s). Th ee pa ien s displayed skin pho o- ype I, 8
pho o- ype II, and 8 pho o- ype III (9). Nine pa ien s ou o
19 had ea lie been ea ed o a non-melanoma skin cance o
p emalignan skin lesions (basal cell ca cinoma n = 2, ac inic
ke a osis n = 2 o bo h n = 5). None o he pa ien s had ea lie
been ea ed o melanoma.
Clinical assessmen o he lesion bo de s using digi al imaging
and Wood’s ligh examina ion
P io o he imaging p ocesses lesions we e e alua ed using
de ma oscopy (De mli e® DL3). Clinical assessmen o he lesion
bo de s was ca ied ou using Wood’s ligh examina ion (Bu -
on®) and digi al pho og aphy (Canon Ixus 130, 14.1 megapixel).
Hype spec al imaging sys em and image analysis
All 19 lesions we e imaged p io o su gical emo al using HIS.
The used handheld HIS was de eloped o he s udy a he VTT
Technical Resea ch Cen e o Finland and Uni e si y o Jy äskylä,
Finland. This p o o ype imaging sys em consis ed o a hype spec-
al image (500–850 nm) (10, 11), ex e nal ligh sou ce o isible
and in a ed ligh , ib e op ic ing ligh and a holde o he image
and he ing ligh . The ield o iew was 12 cm2. HIS acqui ed
he di use e lec ance o he de ec ed skin a eas apidly in a ew
seconds. The acqui ed hype spec al da a cube was analysed using
an assump ion o he linea mix u e model ( e ex componen
analysis, VCA and il e ec o algo i hm FVA) (12–14) o achie e
pu e spec a (endmembe s) o LM/LMM and heal hy skin (Fig.
S11) and o p oduce abundance maps o delinea ion o he lesion
bo de s (Fig. 2, Fig. S21). The hype spec al image and he ana-
lysing p ocess a e shown in Fig. 1, and de ailed in Appendix S11.
His opa hological sampling
The lesions o 5/19 pa ien s we e biopsied be o e ec ui ing o
he s udy and excised immedia ely a e he imaging p ocesses.
The edges o he specimens we e ma ked wi h o ien ing su u es,
and inked o o ien a ion. To help mapping he indings o 14/19
pa ien s, we ook a ge ed 3 mm punch biopsies (2–4 pe pa ien )
om he middle and om lesions bo de s, de ined using he HIS,
and a e wa ds he lesions we e comple ely excised wi h wide
excision ma gins. The biopsy si es and excision ma gins we e
ma ked and pho og aphed. An expe ienced de ma opa hologis
(LJ) examined he samples wi hou any backg ound in o ma ion.
RESULTS
The compa a i e analyses included a o al o 14 LMs
and 5 LMMs loca ed on he ace and scalp (nose n = 1,
ea n = 4, eyelid n = 2, o ehead n = 2 and on he cheek
a ea n = 10) o 19 pa ien s. The in asion dep h (B es-
low hickness) o he LMMs a ied be ween 0.5 and
1.25 mm. The mean lesion a ea was 2.4 cm
2
( ange
1.6–7.6 cm
2
).
In he delinea ion o LM o LMM ma gins, HIS analysis
ma ched he his opa hological analysis in 18/19 (94.7%)
1h p://www.medicaljou nals.se/ac a/con en /?doi=10.2340/00015555-2010
Fig. 2. Len igo maligna melanoma on lowe eyelid (pa ien
19). (a) Lesion in Wood’s ligh , (b) Clinical wide excision
ma gins, (c) Hype spec al abundance map showing
subclinical lesion ex ension (a ows), (d) His ological image
(HE-s aining magni ica ion × 20) o he squa ed a e om
Fig 2 c. A ypical melanocy ic nes s in de mo-epide mal
junc ion and sola elas osis. The wide excision e i ied he
HIS esul s o subclinical lesion ex ension.
Ac a De m Vene eol 95
551
Hype spec al imaging o len igo malignas
cases while in 1/19 (5.3%) cases HIS showed lesion
ex ension no con i med by his opa hology ( alse posi i-
es). In 10/19 (52.6%) o he cases lesion ma gins we e
delinea ed mo e accu a ely (wide , n = 7 o smalle , n = 3)
by HIS han by clinical examina ion wi h Wood’s ligh , as
con i med by his opa hological analysis (Fig 2, Fig S2
1
).
In 8/19 (42.1%) cases he lesion ma gins we e equally
delinea ed by HIS and clinical examina ion, as con i med
by his opa hology. No alse nega i es we e de ec ed when
compa ing HIS de ec ion wi h his opa hology.
In he alse posi i e case an ac inic ke a osis and
benign len igo was p esen his ologically on he LM
bo de s which complica ed he in e p e a ion o he
HIS image.
The lesions we e ope a ed in acco dance wi h cu en
s anda ds by emo ing LMs wi h 5 mm clinical ma gins
and LMMs wi h 10 mm ma gins i ana omically pos-
sible (15). As his was a pilo s udy, he ma gins gi en
by HIS we e no used in he excisions. A e ecei ing
he esul s om he his opa hological analyses, 3/14 o
he LM lesions and 2/5 LMM lesions needed e-excision
because o he subclinical ex ension o he lesion bo -
de s. I he excision bo de s had been selec ed on he
basis o he HIS analysis, 5 e-excisions could ha e
been a oided (Table I).
DISCUSSION
This s udy indica es ha he HIS is capable o de ec ing
he subclinical bo de s o LM and LMM. Impo an ly,
in o e 50% o he cases, he lesion ma gins we e as-
sessed mo e accu a ely by using he HIS han wi h
he clinical me hods. The ad an ages o HIS include
a handheld image wi h a la ge ield o iew (12 cm
2
)
and a quick imaging p ocess. All s udied skin a eas
including he nose and ea s we e sui able o imaging
wi h he HIS and i ed he ield o iew.
The lesions we e emo ed wi h ma gins de e mined
a e delinea ing he umou isually using Wood’s ligh .
Th ee LM pa ien s and 2 LMM pa ien s needed e-ex-
cision because o he his ologically e i ied subclinical
ex ension o he lesions. In e es ingly, i he pa ien s
had ini ially been ope a ed on using ma gins gi en by
HIS, he e-excisions could ha e been a oided. HIS also
seems o be in e sely use ul, since clinical assessmen s
delinea ed 3 LM lesions inco ec ly la ge han depic ed
using HIS and con i med by his opa hology.
Disc imina ion o LM om sun-damaged skin a he
pe iphe y o lesions may also be challenging his ologi-
cally (3). The cy ological a ypia in LM may a y and
be sub le. The di use melanocy ic o e g ow h o sun-
damaged skin and he p esence o benign melanocy es
along he hai ollicles make i challenging o assess
he pe iphe al ma gins o LM. Immunohis ochemis y,
o e.g. MART-1, is some imes used o iden i y LM.
Howe e , also no mal, ch onically sun-exposed skin
has a high numbe o MART-1 posi i e melanocy es
(16, 17). In one case in ou s udy, benign len igines
and subclinical AK su ounding he LM made i di -
icul o co ec ly in e p e he HIS image and led o a
alse posi i e in e p e a ion. These lesions migh ha e
complica ed he his opa hological analysis as well.
Wood’s ligh u ned ou o be o only ma ginal help
in assessing he ma gins o LMs. Especially in cases
whe e also benign len igines we e p esen , he delinea-
ion o LM wi h Wood’s ligh was complica ed. Since
bo h melanin and haemoglobin s ongly abso b isible
and UV ligh (4), a u u e de elopmen al aspec could
be o in eg a e a UV ligh sou ce o HIS o imp o e
isualisa ion o he pigmen a ion.
The e a e se e al comme cially a ailable de ices
o skin cance de ec ion and a magni ude o esea ch
in he ield (18, 19). As a as we know he e a e no
comme cial applica ions o a HIS. P e iously, a ew
echniques ha e been used o assess su gical ma gins
includings: de ma oscopy, con ocal mic oscopy and
op ical cohe ence omog aphy.
De ma oscopy (epiluminescence mic oscopy) helps
in de ining he LM bo de s, bu equi es an expe ienced
de ma oscopis (20). LM on he ace do no show he
classical de moscopic ea u es ound on he o he pa s
o he skin, which makes hei obse a ion mo e chal-
lenging (21). In his s udy de ma oscopy was used as a
diagnos ic aid, bu no o he delinea ion o he lesions.
Con ocal mic oscopy has shown po en ial in e alua-
ing pigmen ed skin lesions and hei ma gins (22). The
de ice de ec s o dep hs o 300 µm, i.e. o he papilla y
Table I. Lesion cha ac e is ics in hype spec al images (HIS)
compa ed wi h clinical e alua ion
Pa ien
B eslow
hickness
(mm)
HIS
use ula
HIS p o ided
no addi ional
in o ma ionb
False
posi i ec
Re-excision
a oidable
1In si u Wide – – +
2In si u Wide – – +
7In si u Wide – – +
16 1.25 mm Wide – – +
19 0.50 mm Wide – – +
6In si u Wide d– – –
17 0.75 mm Wide d– – –
4In si u Smalle – – –
8In si u Smalle – – –
13 In si u Smalle – – –
3In si u – Iden ical – –
5In si u – Iden ical – –
9In si u – Iden ical – –
11 In si u – Iden ical – –
14 In si u – Iden ical – –
15 0.70 mm – Iden ical – –
18 0.70 mm – Iden ical – –
10 In si u – Iden ical – –
12 In si u – +Wide –
aHIS shows lesion ma gins mo e accu a ely compa ed o clinical e alua ion
as con i med his ologically. bLesion bo de s simila ly de ec ed clinically, by
HIS and his ology. cHIS shows lesion wide han his ologically con i med.
dOnly mino subclinical ex ension, no need o e-excision.
Ac a De m Vene eol 95
552 N. Nei aanmäki-Pe u e al.
de mis. The limi a ion in con ocal mic oscopy is a small
ield o iew (FOV 8 × 8 mm mosaic composi e ima-
ges) leading o se e al slow imaging sessions o each
lesion. The me hod lacks any objec i e analysis and
he assessmen o one FOV a ea equi es a leas 5 min
o an expe which makes he me hod slow compa ed
o HIS (23, 24).
Op ical cohe ence omog aphy (OCT), has shown
po en ial in delinea ing he bo de s o non-melanocy ic
skin malignancies (25). As a as we know he e a e no
s udies o he delinea ion o pigmen ed lesions using
OCT. The de ice p o ides high- esolu ion c oss-sec io-
nal images a g ea e dep hs (1.5–2 mm) han con ocal
mic oscopy. The FOV is small (6 × 6 mm), hus making
he imaging p ocess slowe han in HIS. The analysis
emains subjec i e.
We ha e ea lie shown ha he HIS is use ul in he
de ec ion o skin ield cance isa ion (5). In he p esen
s udy HIS showed i s po en ial in he de ec ion o he
subclinical bo de s o LM and LMM. By de ec ing ac-
cu a e ma gins o he lesions, cumbe some e-excisions
could be a oided. In addi ion, HIS could also be used
o spa e acial issue in cases whe e lesion bo de s a e
smalle han shown by clinical assessmen s. HIS can
o e clinicians a p ac ical ool o a non-in asi e de-
linea ion o umou bo de s. As his was a pilo s udy
wi h limi ed cases u he s udies a e wa an ed o
alida e he esul s.
ACKNOWLEDGEMENTS
This s udy was unded by he No o No disk Founda ion’s
No o P eSeed G an .
The au ho s decla e no con lic s o in e es .
REFERENCES
1. Reed JA, Shea CR. Len igo maligna melanoma in si u on
ch onically sun-damaged skin. A ch Pa hol Lab Med 2011;
135: 838–841.
2. Swe e SM, Bold ick JC, Jung SY, Egbe BM, Ha ell JD.
Inc easing incidence o len igo maligna melanoma sub y-
pes: no he n Cali o nia and na ional ends 1990–2000. J
In es De ma ol 2005; 125: 685–691.
3. B euninge H, Schlagenhau B, S oebel W, Schaumbu g-
Le e G, Rassne G. Pa e ns o local ho izon al sp ead o
melanomas: consequences o su ge y and his opa hologic
in es iga ion. Am J Su g Pa hol 1999; 23: 1493–1498.
4. Pa ake as L-R, Halpe n AC, Ma ghoob AA. U ili y o
Wood´s ligh : i e cases om pigmen ed lesion clinic. B
J De ma ol 2005; 152: 1039–1044.
5. Nei aanmäki-Pe u N, G ön oos M, Tani T, Pölönen I,
Ranki A, Saksela O, e al. De ec ing ield cance iza ion
using a hype spec al imaging sys em. Lase s Su g Med
2013; 45: 410–417.
6. Ma in ME, Wabuyele MB, Chen K, Kasili P, Panjehpou M,
Phan M, e al. De elopmen o an ad anced hype spec al
imaging (HSI) sys em wi h applica ions o cance de ec-
ion. Ann Biomed Eng 2006; 34: 1061–1068.
7. Siddiqi AM, Li H, Fa uque F, Williams W, Lai K, Hugh-
son M, e al. Use o hype spec al imaging o dis inguish
no mal, p ecance ous, and cance ous cells. Cance 2008;
114: 13–21.
8. Panasyuk SV, Yang S, Falle DV, Ngo D, Lew RA, F e-
eman J, e al. Medical hype spec al imaging o acili a e
esidual umo iden i ica ion du ing su ge y. Cance Biol
The 2007; 6: 439–446.
9. Fi zpa ick TB. The alidi y and p ac icali y o sun- eac i e
skin ypes I h ough VI. A ch De ma ol 1988; 124: 869–871.
10. Saa i H, Aallos V-V, Holmlund C, Malinen J, Mäkynen J.
Handheld hype spec al image . P oc SPIE 2010; 7680.
11. Saa i H, Pölönen I, Salo H, Honka aa a E, Hakala T, Holm-
lund C, e al. Minia u ized hype spec al image calib a ion
and ua ligh campaigns. P oc Spie 2013; 8889: 10–12.
12. Nascimen o JMP, Dias JMB. Ve ex componen analysis:
A Fas algo i hm o unmix hype spec al da a. IEEE T ans
Geosci Remo e Sensing 2005; 43: 898–910.
13. Bowles J, Palmadesso P, An oniades J, BaumbackM, Rick-
a d LJ. Uses o il e ec o s in hype spec al da a analysis.
P oc SPIE 1995; 2553: 148–157.
14. B o R, De Jong S. A as non-nega i i y-cons ained leas
squa es algo i hm. J Chemom 1997; 11: 393–401.
15. Bichakjian CK, Halpe n AC, Johnson TM, Foo e Hood A,
G ichnik JM, Swe e SM, e al. Ame ican Academy o
De ma ology Guidelines o ca e o he managemen o
p ima y cu aneous melanoma. J Am Acad De ma ol 2011;
65: 1032–1047.
16. McLeod M, Choudha y S, Giannakakis K, Nou i K. Su -
gical ea men s o len igo maligna: a e iew. De ma ol
Su g 2011; 37: 1210–1228.
17. Hendi A, B odland DG, Zi elli JA. Melanocy es in long-
s anding sun-exposed skin: quan i a i e analysis using he
MART-1 immunos ain. A ch De ma ol 2006; 142: 871–876.
18. Calin MA, Pa asca SV, Sa as u R, Calin MR, Don u S.
Op ical echniques o he nonin asi e diagnosis o skin
cance . J Cance Res Clin Oncol 2013; 139: 1083–1104.
19. Fe is LK, Ha is RJ. New diagnos ic aids o melanoma.
De ma ol Clin 2012; 30: 535–545.
20. Robinsson JK. Use o digi al epiluminescence mic oscopy
o help de ine he edge o len igo maligna. A ch De ma ol
2004; 140: 1095–1100.
21. P along P, Ba helie E, Dalle S, Poulalhon N, Deba bieux
S, Thomas L. De moscopy o len igo maligna: epo o
125 cases. B J De ma ol 2012; 167: 280–287.
22. Ca e a C, Palou J, Mal ehy J, Segu a S, Aguile a P, Sale ni
G, e al. Ea ly s ages o melanoma on he limbs o high- isk
pa ien s: clinical, de moscopic, e lec ance con ocal mic o-
scopy and his opa hological cha ac e iza ion o imp o ed
ecogni ion. Ac a De m Vene eol 2011; 91: 137–146.
23. Gui e a P, Moloney FJ, Menzies SW, S e ch JR, Quinn
MJ, Hong A, e al. Imp o ing managemen and pa ien
ca e in len igo maligna by mapping wi h in i o con ocal
mic oscopy. JAMA De ma ol 2013; 149: 692–698.
24. Ca e a C, Puig S, Malhe y J. In i o con ocal e lec-
ance mic oscopy in melanoma. De ma ol The 2012; 25:
410–422.
25. Alawi SA, Kuck M, Wa lich C, Ba z S, McKenzie G, Fluh
JW, e al. Op ical cohe ence omog aphy o p esu gical
ma gin assessmen o non-melanoma skin cance – a p ac-
ical app oach. Exp De ma ol 2013; 22: 547–551.
Ac a De m Vene eol 95