Are You Naked for a Total Body Photography
Int J Dermatol. Author manuscript; available in PMC 2016 November i.
Published in concluding edited form as:
PMCID: PMC5010423
NIHMSID: NIHMS810854
Total trunk photography for pare cancer screening
Lynn T. Dengel
aDepartment of Surgery, University of Virginia Health Systems; Charlottesville, VA, USA
Joshua Judge
aDepartment of Surgery, University of Virginia Health Systems; Charlottesville, VA, USA
David Chen
cDepartment of Biomedical Engineering, Academy of Virginia Health Systems; Charlottesville, VA, U.s.
Scott T. Acton
cDepartment of Biomedical Engineering, University of Virginia Wellness Systems; Charlottesville, VA, U.s.
Anneke T. Schroen
aSection of Surgery, University of Virginia Wellness Systems; Charlottesville, VA, The states
Craig L Slingluff, Jr.
aDepartment of Surgery, Academy of Virginia Health Systems; Charlottesville, VA, USA
Abstract
Groundwork
Total trunk photography may help in melanoma screening, just is not widely applied due to time and cost. We hypothesized that a near-simultaneous automated peel photo-acquisition organization would exist acceptable to patients and could chop-chop obtain full body photographic images that enable visualization of pigmented skin lesions.
Methods
From 2/09–5/09, a written report of 20 volunteers was performed at the University of Virginia to test a prototype 16-camera imaging booth congenital by the research team and to guide development of special purpose software. For each participant, images were obtained before and later on marking ten lesions (5 "easy" and 5 "difficult"), and images were evaluated to guess visualization rates. Imaging logistical challenges were scored past the operator, and participant stance was assessed by questionnaire.
Results
Boilerplate time for epitome capture was 3 minutes (range ii–5). All 55 "easy" lesions were visualized (sensitivity 100%, 90%CI 95–100%) and 54/55 "difficult" lesions were visualized (sensitivity 98%, 90%CI 92–100%). Operators and patients graded the imaging procedure favorably, with challenges identified regarding lighting and positioning.
Conclusions
Rapid-acquisition automated skin photography is viable with a low-cost system, with excellent lesion visualization and participant acceptance. These information provide a basis for employing this method in clinical melanoma screening.
Keywords: Skin cancer screening, melanoma, photography, cancer screening
Introduction
Early detection of melanoma is critical to maximizing a run a risk for cure. Since the vast majority of melanomas are visible on the skin, screening for melanoma through routine skin exams detects the majority of suspicious lesions. However, the sensitivity and specificity of a pare examination is likely altered by the expertise and the retention of the practitioner and patient (Slue et al., 1988;Helfand et al., 2001;Malvehy and Puig, 2002a;Risser et al., 2007). Many lesions are located in areas not visible to the patient (Slue et al., 1988), and this further limits existing approaches.
Primary care physicians are responsible for age-advisable screening of their patients. In the era of decreasing reimbursement and shorter time for patient visits, skin exams have been marginalized. Primary intendance physicians by and large consider digital rectal examination, manual breast exam, and Pap smear as more of import uses of their time than skin exams(Altman et al., 2000). Dermatologists are a logical place to look to fill the gap in skin cancer screening. Unfortunately, there is already a shortage of dermatologists in the United States (Suneja et al., 2001;Tsang and Resneck, Jr., 2006), and further contraction in the effective supply of dermatologists is projected (Suneja et al., 2001;Jacobson et al., 2004). This shortage is exacerbated in underserved medical areas (Suneja et al., 2001). In a contempo study, researchers posing equally new patients called 851 dermatologists to request an appointment for a "changing mole" -- a possible sign of skin cancer: the average wait was more than a month(Tsang and Resneck, Jr., 2006). Many physicians have turned to physician extenders to see the demand for skin cancer screening(Clark et al., 2000;Tsang and Resneck, Jr., 2006), but this still requires training and is subject to all the issues related to physical examination discussed higher up. If a convenient, reliable and affordable method were bachelor for peel cancer screening, it is likely at that place would be increased access and stronger recommendations for annual skin cancer screening.
Diverse technologies take been employed to aid in skin cancer screening. Digital surface microscopy (dermoscopy) is useful in diagnosis and surveillance of skin lesions (Menzies et al., 2001;Terushkin et al., 2010), just it requires formal training and specialized equipment and is very operator-dependent (Bafounta et al., 2001;Malvehy and Puig, 2002a) Digital photography is used more than and more often to certificate a baseline skin examination (Slue et al., 1988;Slue, Jr., 1992;Feit et al., 2004;Risser et al., 2007) or for lesion surveillance with serial imaging (Shriner et al., 1992;Shriner and Wagner, Jr., 1992). Select centers create a body map of these images to facilitate the tracking of lesions over time. (Malvehy and Puig, 2002) Photography as an adjunct to traditional clinician screening exams can improve accuracy and early detection of skin cancer(Slue et al., 1988; Rigel et al., 1989; Shriner et al., 1992; MacKie et al., 1993; Kelly et al., 1997; Rhodes, 1998; Hanrahan et al., 1998; Oliveria et al., 2004). While physicians and patients are interested in photography equally an help to melanoma screening (Hanrahan et al., 2000), adaptation of this engineering every bit a routine population screening mechanism is express by financial and logistical constraints (Terushkin et al., 2010). Near centers use a handheld photographic camera and photographer (professional person photographer, physician or nurse) to acquire an average of 24 images (range 4–l) (Slue et al., 1988;Rhodes, 1998;Nehal et al., 2002;Phelan et al., 2005;Terushkin et al., 2010).
An automated photography system to streamline and standardize this screeining practice has been evaluated in the individual practice setting and found to exist effective at diagnosing thin melanoma (Drugge et al., 2009). Patient satisfaction and feasibility of their imaging method were not reported. Success with this described organisation is promising and supports further research of rapid-photography systems in additional melanoma centers. We developed a novel, near-simultaneous multi-photographic camera automated peel photo acquisition organization. Nosotros hypothesized that this system could quickly capture consummate skin photographs with patients in just 2 positions and could exist acceptable to patients.
Methods
Skin cancer screening survey
Prior to initiating the clinical trial, we initiated a study at our melanoma clinic investigating patient's opinions and adherence to skin cancer screening. After receiving IRB blessing (IRB HSR#13534), nosotros contacted seventy patients through our melanoma clinic. Patients were selected for survey if they had previously agreed to be contacted past e-mail for this purpose and if they had an active email address. The survey gathered information on the patient'south skin cancer history, screening regimen and their opinion about various screening modalities and the time they would be willing to spend for screening. The original survey was distributed electronically in Feb 2008 with two subsequent email reminders in February and March 2008. The survey was completed anonymously. All responses were received by April 2008.
Prototype evolution
Our team initiated development of a epitome device which includes a framed berth measuring 6ft past 6ft by 6ft, mounted with 16 digital cameras (Canon Powershot A520 4MP and Canon PowerShot A80 4MP). As shown schematically in Fig. 1, the cameras are fixed in a four vertical arrays of four cameras each, located in each corner of the square booth. To assistance in groundwork partitioning and to minimize specular reflection, the prototype system walls are draped in a blueish material of relatively consequent color. The cameras are capable of simultaneous capture of 16 high-resolution images of patient skin in a unmarried pose; 24-fleck color images of size 1704×2272 pixels are obtained from each photographic camera. A complete dataset contains multiple acquisitions of patient skin in ii poses, ensuring consummate peel coverage. The cameras are continued via USB extenders into a standard personal computer (PC). The PC is equipped with 2GB of memory and an Intel two Cadre Duo processor. A basic interface to obtain images and automated photo conquering have been developed in the C-sharp programming surround.
Diagram of prototype imaging arrangement, Dermagram. Here, each light-green sphere represents a single camera focused on a different portion of patient peel.
The program currently uses Canon SDK version 7.3, which supports a number of Canon cameras, including the A520 and the A80. In order to allow for simultaneous shutter release, the program calls a procedure for each camera and uses TCP sockets to result commands. Various parameters and modes of the camera tin be controlled through the plan interface. The plan also allows the computer user to preview the subject using the viewfinders of the cameras to aid in calibration if necessary. Afterward the shutter release is activated in the graphics user interface (GUI) and the cameras take their images, they send them back to the computer where they are stored in a folder. using 16 cameras, operated by software. To capture most-complete skin imaging with this device, patients were imaged in two unique positions, 1 continuing and one kneeling on a stool.
Pilot clinical report
From ii/09–five/09, a pilot study of 20 volunteers was performed using this prototype device. The study was designed to allow for optimization of the imaging system during the first cohort of patients. Nine participants were imaged during this development stage and adjustments to patient positioning and the operating organization were made.
The final xi participants were imaged under the definitive design programme for data analysis. Participants were instructed on the correct positioning for the imaging prior to entering the Dermagram berth. A main imaging session was completed, imaging patients in Positions 1 and 2. After initial imaging, a complete skin examination was performed by a physician, and x pigmented skin lesions were identified to be evaluated with the imaging system. These included 5 lesions in difficult locations ("difficult" lesions), defined every bit lesions in a skin fold, in hair-begetting areas, along hair lines, in the umbilicus, behind the ears, between the fingers or toes, and under the chin. They also included 5 "easy" lesions, defined as lesions on the arms and legs, trunk, buttocks, confront and not in areas defined every bit difficult. Skin markers were placed side by side to each of these lesions, and a second series of photographs were obtained in the aforementioned way described above, to certificate the location of these lesions. The maximum diameter of each lesion was recorded. At the completion of the trial, the images from all 11 participants were reviewed by a physician. Marked lesions were scored as identified or not identified on patient images.
Imaging logistical challenges were scored by the operator, and participant stance was assessed past questionnaire.
Results
Skin cancer screening survey
The response rate on the patient survey about skin cancer screening was 73% (51/70). Even in this high-risk patient population (98% of responders study a history of melanoma), 10% of responders had never had a complete pare test, and but 26% had always had photographs taken as function of a skin exam. Nevertheless, 70% wished to accept consummate skin photography, and 80% were interested in having it performed via an automated photograph booth. The majority (70%) of participants was willing to spend any corporeality of time needed to obtain consummate skin photography and the remaining participants reported the following time restrictions: less than 2 min (2%), 10 minutes (4%), 20 minutes (10%), thirty minutes (8%).
Airplane pilot clinical trial lesion detection
Xi participants were imaged under the definitive design for data analysis: 9 males and ii females. Ix had a personal history of melanoma. The median fourth dimension since their last skin exam past a health care professional was 3 months (range 0–12 months). Average fourth dimension for epitome capture was 3 minutes (range 2–5). The 55 "like shooting fish in a barrel" lesions had a mean lesion size of four.seven mm (1–22 mm) and included xiv lesions on the extremities, 37 on the trunk, 2 on the neck and 2 on the face. All 55 "easy" lesions were visualized (sensitivity 100%, 90%CI 95–100%) The 55 "difficult" lesions had a mean lesion size of iii.9 mm (2–xi mm) and included 11 lesions on the extremities, 34 on the trunk, five on the cervix and 5 on the face up. Fifty-four of 55 "difficult" lesions were visualized (sensitivity 98%, 90%CI 92–100%). The lesion that was not detected measured 2mm and was on the participant's right lateral arm, just distal to the elbow, in a dumbo hair-bearing area.
Operator and participant assessment
No adverse events occurred. Operator and participants graded the imaging procedure on a 5 signal scale, with v beingness best and 1 being worst. The hateful operator score for the feasibility and logistics of the organisation was 4.6. Positioning of the subjects and lighting were the biggest challenges with mean scores of three.9 and 4, respectively (Figure 2A). The operator scored the time required favorably, with a mean score of 4.9.
Images acquired with the prototype Dermagram imaging device with original image (left) and and then zooming to 3X (middle) and so (10X), demonstrating image resolution of lesions one–2mm in diameter (correct).
The mean overall participant opinion score was 4.viii, with the most favorable scoring given to the time required (mean 5) and the to the lowest degree favorable score given to being fully naked for imaging (hateful four) and the comfort of position 2 (kneeling, iv) (Figure 2B). The participants were given the option to article of clothing undergarments, and 9/11 participants elected to wear them. The two participants who chose non to habiliment undergarments each scored their comfort with this every bit 5. Overall, the participants would recommend this imaging to others strongly, mean score four.ix.
Word
In patients with atypical moles, skin photography improved detection of new or changing lesions (Barnes and Nordlund, 1987; Halpern et al., 1993) and before detection of melanoma (Rivers et al., 1990). As seen with our survey in this study and by previous reports (Hanrahan et al., 2000), patients would like to participate in photographic screening programs. The utilize of complete peel photography has increased in the past decade and with a CPT code introduced in 2007 (AMA CPT 2007), some support for this screening modality is available. However, access to complete pare photography continues to be limited past logistical and financial constraints on the part of health intendance providers. Access to a rapid-acquisition system with automated paradigm processing and analysis would improve the price: benefit ratio and would facilitate penetration of this type of screening tool into population-based screening programs.
The goal of our total torso imaging system is not to diagnose individual peel lesions but to screen for high-risk lesions that require follow-up examination or biopsy by a health intendance practitioner. Broad adoption of skin photography as a routine screening machinery would allow for monitoring of changes over time in repeated imaging sessions. Documented changes in peel lesions would have advantages over relying on the memory of the patient or doctor to identify change in peel lesions.
The present written report supports the feasibility of rapid-acquisition automatic skin photography, with excellent visualization of pocket-sized lesions and high participant acceptance. Low-cost population-based screening will be facilitated by the ability to acquire images without skilled staff and in less than 5 minutes. Participants scored this organization very favorably. There was a selection bias for loftier-risk individuals, with ix of the 11 final participants having a personal history of melanoma. This limits application of the participant scoring to the population at big; however, these participants have significant experience with clinician skin exams and therefore are familiar with alternate screening tools, calculation strength to their evaluation. Additionally, this higher-run a risk population would be the most important target audience for pare cancer screening, and their credence of an automated imaging-system is critical to broad adoption of the screening tool.
Despite the encouraging findings, this trial as well highlights challenges that demand to exist addressed before broad adoption of this method. The use of standard flash photography, with the employ of multiple cameras with individual flashes, results in competing flashes and light detection with an imaging booth similar this one, where cameras and lights are positioned on reverse sides of the imaging berth. The use of background lighting lonely, however, did not provide optimal illumination of the entire body surface, especially in areas such as the axilla or beneath the chin. Future work is needed to develop a lighting source which is consistent over the body surface and over fourth dimension.
One category the participants scored poorly was the proposition of being (well-nigh) nude for imaging sessions. Confounding factors in this data include that the trial was conducted in a inquiry infinite and was not specifically for clinical determination-making. The participants also found the kneeling position (position #two) uncomfortable. We had designed this position as it would allow us to capture the axilla, bottoms of the feet and inner legs in one position. Given that the participants were happy with the fourth dimension it took and that 70% of our survey respondents were willing to invest any amount of time required, future designs may benefit from using easier patient-positioning at the expense of a marginal increase in time required.
Despite some challenges with this prototype system, lesion detection was excellent, and 109/110 lesions (99%) marked in this pilot report were visualized on the images obtained. Clinical application of this screening tool would be facilitated by systems for piece of cake prototype viewing and conclusion support software to guide a clinician's use of these images. Overall, these data provide a basis for optimizing this method for use in clinical melanoma screening, with future plans to add automated lesion detection and longitudinal lesion tracking.
Imaging sessions scored on a scale of one–5, with five beingness the best and 1 being the worst. Circles correspond hateful values and fault bars represent the maximum and minimum values assigned. A) Operator stance. B) Participant stance.
Acknowledgments
This research was funded by The Thelma R. Swortzel Collaborative Research Award and the Commonwealth Foundation for Cancer Research. Farther funding for inquiry team members was provided past a Cardiovascular Surgery Training Grant - 2T32 HL007849.
Footnotes
Disclosures: Lynn Dengel, Scott Acton, and Craig Slingluff are partners in a limited liability corporation, Dermagram LLC, which was created for the purposes of attaining further funding through STTR grants from the NIH. These grants were non funded and Dermagram LLC currently holds no intellectual belongings with no exterior investors or current revenue streams.
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