DOCSLIB.ORG

Pigmented Vulvar Lesions. Dermatoscopy. Is It Advisable?

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Pigmented Vulvar Lesions. Dermatoscopy. Is It Advisable? "ISSVD - International Society for the Study of Vulvovaginal Disease " PIGMENTED VULVAR LESIONS. DERMATOSCOPY. IS IT ADVISABLE? Damian Ferrario MD. Dermatology Department. Italian Hospital of Buenos Aires Without Conflic Interest PIGMENTED VULVAR LESIONS • Pigmented skin lesions in the vulvar area include nevi, melanoma, melanotic macules (lentiginosis, melanosis), angiokeratomas, seborrheic keratosis, SeborrHeic keratosis AMNGT squamous cell carcinoma, basal cell carcinoma (BCC). • Atypical melanocytic nevi of the genital type (AMNGT) and vulvar melanomas usually affect postmenopausal women and the prognosis is poor. Melanosis Melanoma Pigmented lesions of the vulva are present in 20% of the women who Have Had gynecological examination. Even thougH vulvar pigmented lesions Has a benign prognosis, it causes concern to the patient and to the pHysician, owing to its melanoma-liKe presentation. Vulvar melanosis is the most frequent lesion among these pigmented disorders... but COLPOSCOPY You examine a 40-year-old patient and detect a nevus in the upper labia majora. According to Her, she Has it since childHood. She does not remember whether it grew or not. It is asymptomatic. WHAT IS YOUR BEHAVIOR? A. Do nothing and continue the examination. B. Urgently refer the patient to a dermatologist telling her it may be a melanoma. C. Performing radical You examine a 40-year-old patient and detect a nevus in the region of the labia surgery for suspected majora. According to Her, she Has it since childHood. He does not remember melanoma. whether He grew up. It is asymptomatic. D. Take a biopsy. A. Do nothing and continue the examination. B. Urgently refer the patient to a dermatologist telling her it may be a melanoma. C. Performing radical You examine a 40-year-old patient and detect a nevus in the region of the labia surgery for suspected majora. According to Her, she Has it since childHood. He does not remember melanoma. whether He grew up. It is asymptomatic. D. Take a biopsy. IS DERMATOSCOPY ADVISABLE IN THIS VULVAR LESION? You examine a 40-year-old patient and detect a nevus in the region of the labia majora. According to Her, she Has it since childHood. He does not remember whether He grew up. It is asymptomatic. COLPOSCOPY DERMATOSCOPY What diagnostic data does dermoscopy give me? • Also known as surface microscopy or epiluminescent microscopy. • Dermoscopy is a technique that allows the visualization of pigmented cutaneous lesions in vivo right to the starting edge of the reticular dermis. THe polarized ligHt do not require the use of fluid systems and not necessary contact the skin. • It generates a beam of light that falls on the skin surface at an angle of 20°. • Placing a fluid (gel) at the interface between the epidermis and the device’s glass slide, light reflection is eliminated, allowing the visualization of the dermoscopic features. Allows you to see the different layers of the skin superimposed on a single image. AtropHy Contact dermatitis Erosions, bleeding In genitals is recommended to place gel. These lesions may alter dermoscopy. WHO OWNS THE VULVAR LESIONS? DERMATOLOGIST? GYNECOLOGIST? VULVAR EXAMINATION - GYNECOLOGISTS • Gynecologists are not trained in differential diagnosis of melanocytic lesions (skin and mucosa). • The vulvar examination with colposcopy… you have a partial view. Areas may remain unobserved. VULVAR EXAMINATION - GYNECOLOGISTS • Gynecologists are not trained in differential diagnosis of melanocytic lesions (skin and mucosa). • The vulvar examination with colposcopy… you have a partial view. Areas may remain unobserved. • To examine the vulva, a magnifying head glass is recommended. Large areas of the vulva can be visualized and hands free. Palpable focal lesion is a strong finding Stretch the sKin of suspected melanoma VULVAR EXAMINATION - DERMATOLOGISTS PROBLEMS • In most cases dermatologists do not examine vulvar region properly well, because they hasn’t got a gynecological stretcher. • During dermatoscopy physicians should be in close proximity with the dermatoscope. Leaving the head between patient legs. • They can use only one hand to move the It is necessary an assistant. labial folds of the vulva. VULVAR EXAMINATION - PROBLEMS No-contact dermatoscopy • Polarized dermoscopes can be used to examine lesions without the need to directly contact the mucosal surface. Stretch the skin • But if contact dermatoscopy is used, it is Contact dermatoscopy very likely that the lens will become dirty. • Any transparent plastic shield (such as plastic food wrap) placed between the lesion and the glass plate of the dermoscope will prevent contamination of the scope. Labial minor folds VULVAR EXAMINATION - VIDEODERMASCOPE • It allow a dermoscope probe to be placed on the lesion (contact dermoscopy) while the image is projected on a monitor. • It allows visualizing the lesion and it can be documented in photography to be compared in the second consultation. VULVAR EXAMINATION - VIDEODERMASCOPE • It allow a dermoscope probe to be placed on the lesion (contact dermoscopy) while the image is projected on a monitor. • It allows visualizing the lesion and it can be documented in photography to be compared in the second consultation. • Dermoscopy attachments exist for cell phones that allow image capture and videodermoscopy with the screen of the cell phone acting as a monitor. Are the dermatoscopical patterns differed in the mucosal pigmented lesions? • Dermoscopy plays an potencial role in the diagnosis of suspicious large pigmented lesions or in thin lesions with a diameter less than 6 mm. • Identifying the different dermatoscopic patterns observed on vulvar pigmented lesions, alows to define the best site to perform the biopsy. DERMATOSCOPIC PATTERNS D Globular and paralell Cobblestone C (‘fingerprint-liKe’) A B A Polycircular Pararell B C D Melanosis on the labia minora showing a parallel pattern (uniform linear and curved structures) Common melanocytic nevus showing a structureless pattern Globular pattern Parallel pattern Ring-like pattern CobblestoneliKe Parallel pattern with pattern curved streaks Irregular vessels WHite veil THree or more colours Blue-whitish veil Multicomponent pattern Variables that were strongly related to melanoma THick reticular-liKe and projections Structureless (or Homogeneous) Blue-white veil, irregular black dots Irregular globular and areas of reticular depigmentation (cobblestone) DERMATOSCOPY AND VULVAR AREA • Dermoscopy is a complementary diagnostic method. • It may be helpful in the diagnosis and management of benign and malignant pigmented skin tumors. • It should be based on a good clinic - dermoscopic and histologic correlation. DERMATOSCOPY AND VULVAR AREA • Identifying the different dermatoscopic patterns observed on vulvar pigmented lesions, alows to define the best site to perform the biopsy • Any lesion suspected of being a melanoma should be confirmed by histopathology. • But…The most important message I want to leave today is… THE GREAT WALL OF VAGINA - JAMIE MC CARTNEY GYNECOLOGIST THE SECRET IS “TEAM WORK” DERMATOLOGIST PATHOLOGIST .
Load more

Recommended publications
  • Dermoscopy—The Ultimate Tool for Melanoma Diagnosis
    Dermoscopy—The Ultimate Tool for Melanoma Diagnosis Giuseppe Argenziano, MD,* Gerardo Ferrara, MD,† Sabrina Francione, MD,* Karin Di Nola, MD,* Antonia Martino, MD,* and Iris Zalaudek, MD‡ “We are beginning to move away from clinicopathologic diagnosis into an era of clinico- imaging diagnosis.” This vision became a fact, as the dermatoscope represents nowadays the dermatologist stethoscope. This is not only because dermoscopy reveals a new and fascinating morphologic dimension of pigmented and nonpigmented skin tumors, but also because it improves the recognition of a growing number of skin symptoms in general dermatology. Melanoma detection remains the most important indication of dermoscopy and in melanoma screening the aim of dermoscopy is to maximize early detection while minimizing the unnecessary excision of benign skin tumors. In the last few years, 3 meta-analyses and 2 randomized studies have definitely proven that dermoscopy allows improving sensitivity for melanoma as compared to the naked eye examination alone. This is the consequence of at least 3 issues: first, the presence of early dermoscopy signs that are visible in melanoma much before the appearance of the classical clinical features; second, an increased attitude of clinicians to check more closely clinically banal-looking lesions; third, an improved attitude of clinicians to monitor their patients. Semin Cutan Med Surg 28:142-148 © 2009 Elsevier Inc. All rights reserved. The Dermatologist Stethoscope dots” pattern in psoriasis and the “whitish striae” pattern in lichen planus.15-20 In a recent review of the indications in “ e are beginning to move away from clinicopathologic dermoscopy, more than 35 different inflammatory and infec- 1 Wdiagnosis into an era of clinicoimaging diagnosis.” tious skin diseases have been listed.21 As reported in several This is what Robinson and Callen wrote in 2005, a vision case series, one of the newest applications is represented by that, to our estimation, is slowly becoming true.
    [Show full text]
  • Download PDF File
    ORIGINAL ARTICLE Magdalena Chrabąszcz1 , Cezary Maciejewski2 , Teresa Wolniewicz1, Rosanna Alda-Malicka1, Patrycja Gajda1, Joanna Czuwara1 , Lidia Rudnicka1 1Department of Dermatology, Medical University of Warsaw, Poland 21st Department of Cardiology, Medical University of Warsaw, Poland Access to a dermatoscope during dermatology courses motivates students’ towards thorough skin examination Address for correspondence: ABSTRACT Joanna Czuwara MD, PhD Introduction. Dermatoscope is a tool for a skin examination, used especially in early detection of malignant skin Department of Dermatology lesions. Non-dermatologists are being trained for opportunistic melanoma detection with the usage of dermato- Medical University of Warsaw, Poland scopy, however, still non-satisfactory. This study was aimed to determine whether practical dermoscopy adjunct Koszykowa 82A, 02–008 Warszawa to traditional, lecture and seminar-based medical school curriculum would improve the perceived relevance of e-mail: [email protected] regular skin examination and basic skin lesions differentiation. Material and method. Fourth-year medical students participating in a 3-week-long dermatology course were randomly assigned to two groups: the first one called A with limited access to a dermatoscope and the second one called B, with unlimited access to dermatoscopes throughout the course. All participants answered surveys concerning their attitude towards skin examination, with a rating scale from 1 to 5, before and after the course. Also, all participants completed an image-based dermoscopy test for distinguishing benign from malignant skin lesions. Results. Students assigned to group B significantly improved their perceived importance of routine skin examination (mean scores before 4.38; after 4.57, P = 0.03). No such tendency was observed in group A — before 4.40, after 4.49 (P = 0.29).
    [Show full text]
  • Dermoscopy of Pigmented Skin Lesions (Part
    Dermoscopy of Pigmented Skin Lesions* (Part II) H. Peter Soyer,a MD; Giuseppe Argenziano,b MD; Sergio Chimenti, c MD; Vincenzo Ruocco,b MD aDepartment of Dermatology, University of Graz, Graz, Austria bDepartment of Dermatology, Second University of Naples, Naples, Italy cDepartment of Dermatology, University Tor Vergata of Rome, Rome, Italy * This CME article is partly reprinted from the Book and CD-Rom ’Interactive Atlas of Dermoscopy’ with permission from EDRA (Medical Publishing & New Media) -- see also www.dermoscopy.org Corresponding author: H. Peter Soyer, MD Department of Dermatology, University of Graz Auenbruggerplatz 8 - A-8036 Graz, Austria Phone: 0043-316-385-3235 Fax: 0043-0316-385-4957 E-mail: [email protected] Key words: dermoscopy, dermatoscopy, epiluminescence microscopy, incident light microscopy, skin surface microscopy, melanoma, pigmented skin lesions, clinical diagnosis 1 Dermoscopy is a non-invasive technique combining digital photography and light microscopy for in vivo observation and diagnosis of pigmented skin lesions. For dermoscopic analysis, pigmented skin lesions are covered with liquid (mineral oil, alcohol, or water) and examined under magnification ranging from 6x to 100x, in some cases using a dermatoscope connected to a digital imaging system. The improved visualization of surface and subsurface structures obtained with this technique allows the recognition of morphologic structures within the lesions that would not be detected otherwise. These morphological structures can be classified on
    [Show full text]
  • The ABCD Rule of Dermatoscopy
    The ABeD rule of dermatoscopy High prospective value in the diagnosis ofdoubtful melanocytic skin lesions Franz Nachbar, MD,a Wilhelm Stolz, MD,b Tanja Merkle, MD,a Armand B. Cognetta, MD,c Thomas Vogt, MD,b Michael Landthaler, MD,b Peter Bilek," Otto Braun-Falco, MD,a and Gerd Plewig, MDa Munich and Regensburg, Germany, and Tallahassee, Florida Background: The difficulties in accuratelyassessing pigmented skinlesions are ever present in practice. The recentlydescribed ABCD rule of dermatoscopy(skin surface microscopy at XIO magnification), based on the criteria asymmetry (A), border (B), color (C), and differential structure (D), improved diagnostic accuracy when applied retrospectively to clinical slides. Objective: A study was designed to evaluatethe prospectivevalueof the ABCD rule of der­ matoscopy in melanocyticlesions. Methods: In 172melanocytic pigmented skin lesions, the criteria of the ABeD rule of der­ matoscopy were analyzed with a semiquantitativescoring system before excision. Results:Accordingto the retrospectively determined threshold, tumors with a score higher than 5.45 (64/69 melanomas[92.8%]) wereclassified as malignant,whereas lesionswith a lowerscorewereconsideredas benign(93/103 melanocyticnevi [90.3%n.Negative predic­ tivevaluefor melanoma (True-Negative+ [True-Negative+ False-Negative)) was 95.8%, whereas positive predictive value (True-Positive+ [True-Positive + False-Positivel) was 85.3%. Diagnostic accuracy for melanoma (True-Positive + [True-Positive+ False­ Positive + False-Negative])was80.0%,comparedwith64.4% by the nakedeye. Melanoma showed a mean final dermatoscopy SCore of 6.79 (SD, ± 0.92), significantly differing from melanocytic nevi (mean score,4.27 ± 0.99; p < O.oI , U test), Conclusion: The ABeD rule can be easilylearned and rapidly calculated, and has proven to be reliable.
    [Show full text]
  • Dermatoscopy of Verrucous Pigmented Lesions Is Essential for Choosing the Appropriate Treatment
    Dermatoscopy of Verrucous Pigmented Lesions is Essential for Choosing the Appropriate Treatment VIRGINIA CHIŢU1, 3, SABINA ZURAC2, 3, ALINA E. CIPI4 1First Department of Dermatology, “Colentina” Clinical Hospital, Bucharest, Romania 2Department of Pathology, “Colentina” Clinical Hospital, Bucharest, Romania 3“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 4“Regina Maria” Private Healthcare Network, Bucharest, Romania Dermatoscopy, as a noninvasive rapid method, which allows the viewing of melanin in the epidermis and papillary dermis, has an important role in diagnosis of the pigmented lesions localized on skin, mucous membrane, scalp and nails. The term of verrucous pigmented lesions includes a series of non-melanocytic and melanocytic, benign and malignant lesions. Among these, the most frequent is the seborrheic keratosis , a common epidermal tumor, affecting the sun exposed areas of adult. At the other end of the spectrum regarding the frequency is the seborrheic keratosis-like melanoma, whose underdiagnosis has a serious impact on the patient’s life. In this work we present the clinical and dermoscopical aspects of three cases of verrucous pigmented lesions (two seborrheic keratoses and one seborrheic keratosis-like melanoma) that determined the diagnostic algorithm as well as the therapeutic approach. The above-presented cases underline the importance of dermatoscopy to determine the malignant potential of the pigmented lesions, the final appropriate treatment being possible after the histopathologic confirmation.
    [Show full text]
  • Dermoscopy of Benign and Malignant Neoplasms in the Pediatric Population Helen C
    Dermoscopy of Benign and Malignant Neoplasms in the Pediatric Population Helen C. Haliasos, MD,* Iris Zalaudek, MD,† Josep Malvehy, MD,‡ Christoph Lanschuetzer, MD,§ Helmut Hinter, MD,§ Rainer Hofmann-Wellenhof, MD,† Ralph Braun, MD,ሻ and Ashfaq A. Marghoob, MD† Dermoscopy is a noninvasive technique that enables visualization of subsurface colors and structures within the skin that are imperceptible to the naked eye. The dermatoscope allows the physician to examine both the macroscopic and microscopic primary morphology of skin lesions, identify subtle clinical clues, confirm naked-eye clinical diagnoses, and monitor treatment progress while posing little threat to the young patient. Dermoscopic findings have been formulated into diagnostic criteria that assist experienced clinicians in differentiating benign and malignant neoplasms. In this review, clinical morphology of melanocytic nevi and melanoma in the pediatric population is examined and the relevant dermoscopic findings and histopathologic correlates that aid in the diagnosis and manage- ment of these lesions are described. Semin Cutan Med Surg 29:218-231 © 2010 Published by Elsevier Inc. hildren, like their adult counterparts, often present to sified as acquired melanocytic nevi if they develop many Cthe dermatologist with pigmented lesions that are new months to years after birth. or changing. Unique to the pediatric population, however, is Although rare, the incidence of pediatric melanoma is in- that they are in a dynamic growing phase of life. One sign of creasing, and it has become imperative that clinicians include this dynamic phase is manifest by the development, growth, melanoma in the differential diagnosis of atypical pigmented and occasional involution of nevi. In addition, children with and even amelanotic lesions in children.
    [Show full text]
  • Digital Dermoscopy Analysis in the Diagnosis of Acral and Nail Melanocytic Tumors
    Danijela D. Dobrosavljević et al. Serbian Journal of Dermatology and Venereology 2009; 2: 74-79 Myofibroblastic dermatofibroma DOI: 10.2478/v10249-011-0007-y Digital dermoscopy analysis in the diagnosis of acral and nail melanocytic tumors Danijela D. DOBROSAVLJEVIĆ1, Dimitrije BRAŠANAC2 Silvana LUKIĆ3 and Ljiljana MEDENICA1* 1Institute of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia 2Institute of Pathology, School of Medicine, Belgrade 3Institute of Oncology of Serbia, Department of Pathology *Correspondence: Danijela D. DOBROSAVLJEVIĆ, E-mail: [email protected] UDC 616.596-006-071 Abstract Digital dermoscopy (epiluminiscence microscopy) is a technology for in vivo imaging of the skin used for the differentiation of pigmented skin lesions. Melanocytic tumors and pigmentations of the nails and acral skin regions represent differential diagnostic problems that can hardly be evaluated with the naked eye, especially at an early stage. Two patients with a total of three very suspicious lesions underwent dermoscopy. Clinical diagnoses were as follows: subungual hemorrhage, plantar wart (previously treated as a plantar wart several times) and acral melanoma. Dermoscopy increased the suspicion to: subungual melanoma, acral amelanotic melanoma and acral nevus, respectively. Histologic examination has verified the following diagnoses: subungual melanoma, acral lentiginous melanoma and acral junctional nevus. Dermoscopic examination of pigmented structures on the above-mentioned sites is a very useful adjunct in establishing accurate diagnosis that can help in differentiating benign from malignant lesions. lantar and subungual melanomas, compared world of colors and structures, invisible with the Pwith other lower extremity melanomas, are very naked eye (7-13). Dermoscopy is used for early difficult to diagnose, especially at an early stage (1, 2).
    [Show full text]
  • DERMOSCOPY of INFLAMMATORY CONDITIONS: the JOURNEY SO FAR *Balachandra S
    DERMOSCOPY OF INFLAMMATORY CONDITIONS: THE JOURNEY SO FAR *Balachandra S. Ankad, Savitha L. Beergouder Rajiv Gandhi University of Health Sciences, Bengaluru, India *Correspondence to [email protected] Disclosure: The authors have declared no conflicts of interest. Received: 20.06.17 Accepted: 12.09.17 Citation: EMJ Dermatol. 2017;5[1]:98-105. ABSTRACT The use of dermoscopy in general dermatological practice has recently increased. Its non-invasive nature means it is being practiced frequently by dermatologists to diagnose various skin conditions. Dermoscopy, also known as dermatoscopy, allows dermatologists to quickly visualise skin structures up to the papillary dermis level. The skin patterns seen under dermoscopy are usually due to pigment and vascular structures; melanin and haemoglobin play major roles and give different patterns depending on the skin condition and pathological changes. Many inflammatory diseases are encountered by clinicians in daily practice; at times they are indistinguishable to the naked eye and a biopsy is required to confirm the diagnosis. Dermoscopy is a useful tool in the diagnosis and differentiation of inflammatory skin conditions and is aptly termed inflammoscopy when used in these situations. Inflammoscopy demonstrates the distinct characteristic patterns of many conditions and aids accurate diagnoses. In this article, the importance of dermoscopy in the diagnosis of relatively common inflammatory conditions, such as eczema, psoriasis, lichen planus, pityriasis rosea, pityriasis lichenoides et varioliformis acuta, pityriasis lichenoides chronica, and discoid lupus erythematosus, is highlighted. Here, an overview of dermoscopic patterns in each of these conditions is emphasised. Keywords: Dermoscopy, inflammatory, psoriasis, lichen planus (LP), pityriasis rosea (PR), pattern, diagnosis. INTRODUCTION enabling physicians to diagnose the skin disease accurately.
    [Show full text]
  • Dermoscopy of Difficult-To-Diagnose Melanomas
    PROFESSIONAL ARTICLE Serbian Journal of Dermatology and Venereology 2016; 8 (3): 121-127 DOI: 10.1515/sjdv-2016-0011 Dermoscopy of difficult-to-diagnose Melanomas Chrysoula PAPAGEORGIOU, Demetrios IOANNIDES, Zoe APALLA, Efstratios VAKIRLIS, Elisabeth LAZARIDOU, Eleni SOTIRIOU, Aimilios LALLAS1 1First Department of Dermatology, Aristotle University, Thessaloniki, Greece *Correspondence: Lallas Aimilios, [email protected] OPEN UDC 616.5-006.8-073/-076 Abstract Dermoscopy is a non-invasive procedure that allows the evaluation of cutaneous lesions, and is considered to be a useful tool that improves the diagnostic accuracy of melanoma. Many dermoscopic criteria of melanoma have been established and several algorithms have been created for melanoma detection. However, the recognition of some melanomas remains challenging. Melanomas on specific body sites, melanomas in patients with multiple atypical moles, and nodular melanomas represent the most difficult-to-recognize melanoma subtypes, since they typically lack the “classic” melanoma-specific criteria. This paper provides an update on dermoscopy of difficult-to-diagnose melanomas by summarizing the newest data. Lastly, we highlight the importance of digital dermoscopy in the follow-up of melanocytic lesions for the detection of incipient melanomas while maintaining a low excision rate. Key words Dermoscopy; Melanoma; Diagnosis; Skin Neoplasms ermoscopy is a non-invasive diagnostic proce- dotted vessels, or milky-red areas are also a common Ddure that allows the visualization of structures finding (4 - 6). located in the epidermis, dermoepidermal junction and Sadayasu et al. suggested the presence of a sudden papillary dermis, that normally cannot be seen with change of the intralesional color, from a blue-gray the naked eye (1).
    [Show full text]
  • Dermatoscopy: Chaos and Clues a Decision Algorithm for Pigmented Skin Lesions
    COVER FOCUS Dermatoscopy: Chaos and Clues A decision algorithm for pigmented skin lesions. BY CLIFF ROSENDAHL, MBBS, PHD he first references to dermatoscopy are from the 1920s, Saphier first using the term in 1923. It is now established that use of a dermatoscope in clinical practice increases diagnostic accuracy and at least inT Australasia it is considered to be the standard of care in assessing patients with pigmented skin lesions. There is also increasing evidence that dermatoscopy is useful for the diag- nosis of non-pigmented skin lesions. This article, based on a presentation at the 2013 Cosmetic Surgery Forum in Las Vegas, discusses an algorithm developed by collaboration between colleagues from the Medical University of Vienna, Austria and The University of Queensland, Australia, for the dermatoscopic assessment of pigmented skin lesions.1 The chaos and clues algorithm was evaluated in a study of 463 consecutively treated pigmented skin lesions (including Figure 1. Be suspicious of a lesion that looks like an evolved or 29 melanomas, 20 of which were in situ) in a general practice created complex object. in Australia. The algorithm was found to have a sensitivity of 90.6 percent and a specificity of 62.7 percent for the diagno- With respect to dermatoscopic chaos, irregularity of shape sis of malignancy of any type in the test series used.2 does not matter. Also perfect symmetry is not expected in nature and is not required for a lesion not to be biologically DEFINING PATTERNS symmetrical Natural laws favor symmetry, and as malignant cells defy Asymmetry has been a clue to malignancy in pre- natural laws, not responding to normal growth-controlling ceding methods, including the classic pattern analysis feed-back mechanisms, they have a tendency to rapidly (Pehamburger, 1987), the ABCD method (Stolz, 1994), become asymmetrical, or chaotic.
    [Show full text]