A new approach for presurgical margin assessment by reflectance confocal microscopy of basal cell carcinoma

Reflectance Confocal Microscopy Can Help Differentiate Adult Xanthogranulomatous Disease from Xanthelasma-A Case Report

Background: Adult xanthogranulomatous disease (AXD) is a rare histiocytic disorder with systemic potential, while xanthelasma palpebrarum (XP) is a common xanthoma often linked to lipid disorders. Differentiating these conditions is challenging due to overlapping features. Reflectance confocal microscopy (RCM), a non-invasive imaging tool, offers high-resolution visualization of skin structures and may aid diagnosis. Methods: We present a 71-year-old woman with periocular lesions. RCM was used to evaluate the lesions, identifying cellular and structural features. The findings were confirmed through histopathology, followed by surgical excision. Postoperative monitoring utilized RCM and LC-OCT. Results: RCM identified Touton giant cells, foamy histiocytes, and fibrosis, helping to distinguish xanthogranuloma from xanthelasma. Histopathology confirmed the diagnosis, and the patient underwent successful lesion excision without complications. Conclusions: This case underscores RCM's utility as a diagnostic adjunct for differentiating AXD from XP in sensitive regions like the periocular area. The combined use of RCM and LC-OCT enhances monitoring for recurrence. While histopathology remains the diagnostic gold standard, RCM shows promise as a non-invasive tool, warranting further research to validate its role and develop standardized clinical protocols.

Novel imaging techniques for tumor margin detection in basal cell carcinoma: a systematic scoping review of FDA and EMA-approved imaging modalities

Mohs micrographic surgery (MMS) is the gold standard for removing basal cell carcinomas (BCCs) due to its ability to guarantee 100% margin evaluation through frozen section histopathology, offering the highest cure rate among current treatments. However, noninvasive imaging technologies have emerged as promising alternatives to clinical assessment for defining presurgical margins. This systematic scoping review examines the efficacy of these imaging modalities, focusing on those approved for clinical use by the United States Food and Drug Administration (FDA) or the European Medicines Agency (EMA). A systematic search of EMBASE, Scopus, PubMed, and the Cochrane Public Library databases identified 11 relevant studies out of 2123 records, encompassing 644 lesions across five imaging techniques. The findings suggest that dermoscopy, high-frequency ultrasound (HFUS), optical coherence tomography (OCT), line-field optical coherence tomography (LC-OCT), and reflectance confocal microscopy (RCM) show potential in detecting BCC margins, which could enhance MMS by providing better preoperative planning, informing patients of expected defect size, aiding in reconstruction decisions, and reducing overall procedure costs. This review discusses the benefits and limitations of each technique, offering insights into how these innovations could influence the future of BCC management. Emerging imaging techniques could enhance MMS by improving BCC margin assessment and reducing costs. Their adoption will depend on price and ease of use.

S2k guideline basal cell carcinoma of the skin (update 2023)

Basal cell carcinoma is the most common malignant tumor in the fair-skinned population and its incidence continues to rise. An update of the S2k guideline with the participation of all specialist societies familiar with the clinical picture and previous literature research is of great importance for the quality of care for affected patients. In addition to epidemiology, diagnostics and histology are discussed. After risk stratification, therapy is divided into topical, systemic and radiation therapy. Surgical removal remains the treatment of first choice in most cases. The approval of anti-PD1 inhibitors for locally advanced and metastatic tumors has opened up a new option in second-line therapy (after hedgehog inhibitors).

Ex Vivo Confocal Microscopy Speeds up Surgical Margin Control of Re-Excised Skin Tumors and Greatly Shortens In-Hospital Stay

BACKGROUND/OBJECTIVES

To ensure that non-melanoma skin cancer (NMSC) is completely removed in healthy tissue, micrographically controlled surgery (3D histology) is often performed, which can prolong the inpatient stay. This study examined ex vivo reflectance confocal microscopy (evRCM) for perioperative assessment of surgical margins, specifically in cases where re-excision was necessary due to incomplete removal of cutaneous tumor tissue.

METHODS

NMSC re-excisions were evaluated using evRCM by a cutaneous surgeon, with retrospective review by an independent pathologist when results differed from histology.

RESULTS

evRCM demonstrated high specificity (0.96; 95% CI, 0.90-0.99) but low sensitivity (0.20; 95% CI, 0.06-0.51). Unlike pathology, which discards outer surgical margins, evRCM examined the true surgical margins. Retrospective pathology analysis of the misdiagnosed cases confirmed that 25% (n = 2/8) were false negative and 75% (n = 6/8) were potentially false positive, resulting in a sensitivity of 0.2-0.8. Notably, evRCM led to a 113-day reduction in in-hospital stays, probably resulting in increased patient satisfaction and cost-effectiveness.

CONCLUSIONS

evRCM was valuable for speeding up the assessment of surgical margins in patients with re-excised NMSC. Proper tissue preparation and assessment require interdisciplinary collaboration between cutaneous surgeons, pathologists, and physician assistants, emphasizing the need for standardized operating procedures.

Hyperspectral imaging with machine learning for in vivo skin carcinoma margin assessment: a preliminary study

Surgical excision is the most effective treatment of skin carcinomas (basal cell carcinoma or squamous cell carcinoma). Preoperative assessment of tumoral margins plays a decisive role for a successful result. The aim of this work was to evaluate the possibility that hyperspectral imaging could become a valuable tool in solving this problem. Hyperspectral images of 11 histologically diagnosed carcinomas (six basal cell carcinomas and five squamous cell carcinomas) were acquired prior clinical evaluation and surgical excision. The hyperspectral data were then analyzed using a newly developed method for delineating skin cancer tumor margins. This proposed method is based on a segmentation process of the hyperspectral images into regions with similar spectral and spatial features, followed by a machine learning-based data classification process resulting in the generation of classification maps illustrating tumor margins. The Spectral Angle Mapper classifier was used in the data classification process using approximately 37% of the segments as the training sample, the rest being used for testing. The receiver operating characteristic was used as the method for evaluating the performance of the proposed method and the area under the curve as a metric. The results revealed that the performance of the method was very good, with median AUC values of 0.8014 for SCCs, 0.8924 for BCCs, and 0.8930 for normal skin. With AUC values above 0.89 for all types of tissue, the method was considered to have performed very well. In conclusion, hyperspectral imaging can become an objective aid in the preoperative evaluation of carcinoma margins.

One-Stop Shop: Diagnosis and Treatment of Basal Cell Carcinoma in One Step

Monitoring the tumor margins of basal cell carcinomas is still a challenge in everyday clinical practice. Usually, the clinical margins of the tumor are marked by the naked eye or, even better, with dermoscopy before surgery and then examined in detail after the operation using histological examination. In order to achieve tumor freedom, several surgical steps are sometimes necessary, meaning that patients spend longer periods in hospital and the healthcare system is burdened more as a result. One way to improve this is the one-stop shop method, which requires precise diagnostics and margin marking before and during surgery so that tumor freedom can be achieved after just one surgery. For this reason, the current status of the diagnosis and treatment of basal cell carcinomas before and after surgery is to be examined following extensive literature research using devices and methods that have already been tested in order to determine how a simplified process of tumor margin control of basal cell carcinomas can be made possible both in vivo and ex vivo.

Combining Reflectance Confocal Microscopy, Optical Coherence Tomography and Ex-Vivo Fluorescence Confocal Microscopy for Margin Assessment in Basal Cell Carcinoma Excision

INTRODUCTION

Recent developments of noninvasive, high-resolution imaging techniques, such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT), have enhanced skin cancer detection and precise tumor excision particularly in highly aggressive and poorly defined basal cell carcinomas (BCCs).

OBJECTIVES

The aim of this pilot study is to assess the feasibility and reproducibility of a systematic clinical workflow combining noninvasive (RCM-OCT) and invasive fluorescence confocal microscopy (FCM) imaging modalities in pre- and intra-surgical evaluations of the lateral and deep margins of BCC.

METHODS

Superficial incisions were made 2 mm beyond the clinical-dermoscopic BCC margins. Lateral margins were then explored with OCT and RCM. In positive margins, a further cut was made 2 mm distal from the previous. A final RCM/OCT-based double-negative margin was drawn around the entire perimeter of the lesion before referring to surgery. The freshly excised specimen was then examined with FCM (ex-vivo) for the evaluation of the deep margin. Histopathologic examination eventually confirmed margin involvement.

RESULTS

The study included 22 lesions from 13 patients. At the end of the study, 146 margins-106 negative (73%) and 40 positive (27%) at RCM/OCT-were collected. The RCM/OCT margin evaluation showed an overall sensitivity of 100% and a specificity of 96.3%. The overall positive margins diagnostic accuracy was 98.2%. Reproducibility was evaluated on recorded images and the raters showed a substantial inter-observer agreement on both RCM (κ = 0.752) and OCT images (κ = 0.724).

CONCLUSIONS

The combined RCM/OCT/FCM ex-vivo approach noninvasively facilitates the presurgical and intrasurgical lateral and deep margin assessment of poorly defined BCCs.

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

Non-invasive imaging techniques in presurgical margin assessment of basal cell carcinoma: Current evidence

BACKGROUND

The diagnosis of basal cell carcinoma (BCC) is based on clinical and dermoscopical features. In uncertain cases, innovative imaging techniques, such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT), have been used. The main limitation of these techniques is the inability to study deep margins. HFUS (high-frequency ultrasound) and the most recent UHFUS (ultra-high-frequency ultrasound) have been used in various applications in dermatology, but they are not yet routinely used in the diagnosis of BCC. A key point in clinical practice is to find an imaging technique that can help to reduce post-surgical recurrences with a careful presurgical assessment of the lesional margins. This technique should show high sensitivity, specificity, reproducibility and simplicity of execution. This concept is very important for the optimal management of patients who are often elderly and have many comorbidities. The aim of the paper is to analyse the characteristics of current imaging techniques and the studies in the literature on this topic.

MATERIALS AND METHODS

The authors independently searched the MEDLINE, PubMed, Embase, Scopus, ScienceDirect and Cochrane Library databases for studies looking for non-invasive imaging techniques for the presurgical margin assessment of BCC.

RESULTS

Preoperative study of the BCC subtype can help to obtain a complete excision with free margins. Different non-invasive imaging techniques have been studied for in vivo evaluation of tumour margins, comparing the histologic evaluation with a radical surgery. The possibility to study the lateral and deep margins would allow a reduction of recurrences and sparing of healthy tissue.

CONCLUSION

HFUS and UHFUS represent the most promising, non-invasive techniques for the pre-operative study of BCC facilitating the characterization of vascularization, deep lateral margins and high-risk subtypes, although they are limited by insufficient literature unlike RCM and OCT.

Imaging technologies for presurgical margin assessment of basal cell carcinoma

Basal cell carcinoma is the most common cancer worldwide, necessitating the development of techniques to decrease treatment costs through efficiency and efficacy. Mohs micrographic surgery, a specialized surgical technique involving staged resection of the tumor with complete histologic evaluation of the peripheral margins, is highly utilized. Reducing stages by even 5% to 10% would result in significant improvement in care and economic benefits. Noninvasive imaging could aid in both establishing the diagnosis of suspicious skin lesions and streamlining the surgical management of skin cancers by improving presurgical estimates of tumor sizes. Herein, we review the current state of imaging techniques in dermatology and their applications for diagnosis and tumor margin assessment of basal cell carcinoma prior to Mohs micrographic surgery.

Diagnostics Using Non-Invasive Technologies in Dermatological Oncology

The growing incidence of skin cancer, with its associated mortality and morbidity, has in recent years led to the developing of new non-invasive technologies, which allow an earlier and more accurate diagnosis. Some of these, such as digital photography, 2D and 3D total-body photography and dermoscopy are now widely used and others, such as reflectance confocal microscopy and optical coherence tomography, are limited to a few academic and referral skin cancer centers because of their cost or the long training period required. Health care professionals involved in the treatment of patients with skin cancer need to know the implications and benefits of new non-invasive technologies for dermatological oncology. In this article we review the characteristics and usability of the main diagnostic imaging methods available today.

Real-time Analysis of Skin Biopsy Specimens With 2-Photon Fluorescence Microscopy

Importance

Nonmelanoma skin cancers (NMSCs) are primarily diagnosed through paraffin section histologic analysis of skin biopsy specimens that requires days to weeks before a formal diagnosis is reported. Two-photon fluorescence microscopy (TPFM) has the potential for point-of-care diagnosis of NMSC and other dermatologic conditions, which could enable same-visit diagnosis and treatment.

Objective

To demonstrate that TPFM imaging of NMSC can occur within minutes of obtaining biopsies and provide similar histological features to those of conventional histology and evaluate TPFM diagnostic performance with respect to conventional histology.

Design, Setting, and Participants

This comparative effectiveness pilot study examined 29 freshly excised biopsies from confirmed NMSC lesions in patients presenting for treatment. Biopsies underwent imaging immediately with TPFM on site at Rochester Dermatologic Surgery (Victor, New York) between October 2019 and August 2021. The imaged biopsies were subsequently submitted for paraffin histology to produce coregistered images. Twelve of these coregistered image pairs (41.4%) were used as a training set. Fifteen (51.7%) were used in a masked evaluation by a board-certified dermatopathologist. Two (6.9%) were excluded from the study before evaluation because they could not be coregistered.

Main Outcomes and Measures

Sensitivity, specificity, and accuracy of TPFM for NMSC biopsies were evaluated compared with conventional histology.

Results

Fourteen of the 15 biopsy specimens (93.3%) in the evaluation set were identically diagnosed with TPFM and paraffin histology. The TPFM had 100% sensitivity (95% CI, 48%-100%), 100% specificity (95% CI, 69%-100%), and 100% accuracy (95% CI, 78%-100%) for basal cell carcinoma diagnosis. For squamous cell carcinoma diagnosis, TPFM had 89% sensitivity (95% CI, 52%-100), 100% specificity (95% CI, 54%-100%), and 93% accuracy (95% CI, 68%-100%). For overall NMSC diagnosis, TPFM had a 93% sensitivity (95% CI, 66%-100%), 100% specificity (95% CI, 3%-100%), and 93% accuracy (95% CI, 68%-100%). Examination of the 1 discordant pair revealed mismatched imaging planes as the source of error.

Conclusions and Relevance

The results of this comparative effectiveness pilot study suggest that TPFM captures histological characteristics of NMSC that are present in conventional histology, which reveals its potential as a rapid, point-of-care diagnostic alternative that does not need extensive sample preparation or retraining for image evaluation. Further validation of TPFM imaging performed for a larger cohort is needed to fully evaluate its diagnostic accuracy and potential effect within the field.

Manually scanned single fiber optical coherence tomography for skin cancer characterization

Optical coherence tomography (OCT) is a cross-sectional imaging modality based on low coherence light interferometry. Within dermatology, it has found applications for in vivo diagnostic imaging purposes, as well as to guide Mohs micrographic surgery (MMS), due to its ability to visualize skin morphology up to several millimeters in depth. However, standard OCT probes have a large footprint and capture an extended area of the skin, making it difficult to precisely pinpoint clinically relevant location being imaged. Mohs surgeons stand to benefit from a handheld in vivo imaging device that can accurately trace surgical margins. In this study, we demonstrate the use of a single fiber OCT (sfOCT) instrument. Our imaging system features a miniature common path single fiber probe, and a novel speckle decorrelation technique that generates distortion free 2D images from manual scanning.By manually moving the single-fiber probe across the region of interest, the user can perform a lateral OCT scan while visualizing the location of the probe during data acquisition. Using the sfOCT, we have identified normal skin morphology, qualitatively correlated features of basal cell carcinoma and squamous cell carcinoma with histopathology, and quantified the disruption of the dermo-epidermal junction OCT pattern in skin tumors-each demonstrating the potential of utilizing sfOCT to differentiate tumor from normal skin. Using this imaging tool, a Mohs surgeon can enhance determination of surgical margins for the first stage of MMS, potentially decreasing the time and number of stages required for complete tumor removal.

Dermoscopic Findings in the Presurgical Evaluation of Basal Cell Carcinoma. A Prospective Study

BACKGROUND

Surgery is the best treatment for basal cell carcinoma (BCC); however, incomplete excisions are possible.

OBJECTIVE

Assessment of the accurateness of dermoscopy and clinical evaluation in the detection of borders of BCC and description of dermoscopic findings in clinically healthy tissue surrounding BCC.

MATERIALS AND METHODS

Eighty-eight lesions with clinical dermoscopic diagnosis of BCC were examined clinically and dermoscopically, to delineate the correct site of surgical incision, demarcating the respective margins with colred dermographic pencils. Specific dermoscopic features were searched in the skin adjacent to the demarcated clinical margin.

RESULTS

In 29 of 88 lesions, clinical and dermoscopic margins of the tumor coincided. In the remaining 59 (67%), 10 (16.9%) presented, in the lesion area identified under dermoscopy, classical criteria for BCC and 57 (96.6%) nonclassical criteria. Differences between clinical and dermoscopic margins were significantly more frequent in superficial BCCs (p = .006). The frequency was not significantly different (p = .85) in relation to body sites.

CONCLUSION

Dermoscopy improves the identification of margins for surgical excision in BCC. The observation of nontraditional dermoscopic criteria of BCC, mainly pink-white areas and short telangiectasias in the area between clinically and dermoscopically detected margins, helps to define the actual tumoral margins and to achieve a really radical excision.

Routine application of ex vivo confocal laser scanning microscopy with digital staining for examination of surgical margins in basal cell carcinomas

BACKGROUND AND OBJECTIVES

Ex vivo confocal laser scanning microscopy (CLSM) allows histologic examination of native tissue based on tissue reflection and nuclear fluorescence staining. The newly introduced digital staining process almost perfectly mimics conventional hematoxylin and eosin (HE) slides. The aim was to evaluate the new method in clinical routine, with regard to quality of findings and time requirements, in the examination of surgical margins of basal cell carcinomas.

PATIENTS AND METHODS

78 patients with 101 basal cell carcinomas were prospectively enrolled. Surgery was performed either with complete margin control (n = 60) or as elliptical excision (n = 41). Immediately after excision specimens were scanned with CLSM and then routinely processed by conventional histopathology. Blinded evaluation of images and slides was performed by a dermatopathologist.

RESULTS

Basal cell carcinomas were excellently recognizable by CLSM directly after excision, and the use of digital staining did not require any adjustment of the examiner's visualization preferences. CLSM images showed a sensitivity of 73.6 % and a specificity of 96.5 % compared to conventional HE stained slides. Erroneous findings were often due to limited assessment potential in cases where the epidermis could not be fully visualized.

CONCLUSIONS

CLSM with digital HE staining is very well suited to diagnose basal cell carcinomas and their incision margins even under routine conditions and thus represents a tissue-saving alternative to rapid cryostat sectioning.

Clinical Applications of In Vivo and Ex Vivo Confocal Microscopy

Confocal laser scanning microscopy (CLSM) has been introduced in clinical settings as a tool enabling a quasi-histologic view of a given tissue, without performing a biopsy. It has been applied to many fields of medicine mainly to the skin and to the analysis of skin cancers for both in vivo and ex vivo CLSM. In vivo CLSM involves reflectance mode, which is based on refractive index of cell structures serving as endogenous chromophores, reaching a depth of exploration of 200 μm. It has been proven to increase the diagnostic accuracy of skin cancers, both melanoma and non-melanoma. While histopathologic examination is the gold standard for diagnosis, in vivo CLSM alone and in addition to dermoscopy, contributes to the reduction of the number of excised lesions to exclude a melanoma, and to improve margin recognition in lentigo maligna, enabling tissue sparing for excisions. Ex vivo CLSM can be performed in reflectance and fluorescent mode. Fluorescence confocal microscopy is applied for “real-time” pathological examination of freshly excised specimens for diagnostic purposes and for the evaluation of margin clearance after excision in Mohs surgery. Further prospective interventional studies using CLSM might contribute to increase the knowledge about its application, reproducing real-life settings.

Preoperative Evaluation through Dermoscopy and Reflectance Confocal Microscopy of the Lateral Excision Margins for Primary Basal Cell Carcinoma

Complete removal of malignant skin lesions with minimal impact on the aesthetic and functional aspects is the ideal of every dermatologic surgeon. Incomplete surgical excisions and tumor recurrences of basal cell carcinomas (BCC) commonly occur due to the subclinical extension of tumor lateral margins. Presently, the lateral excision margins for BCC cannot be objectively assessed preoperatively, dermoscopy proving to be relatively inefficient in this respect. The question is whether BCC lateral excision margins can be precisely determined preoperatively through the use of complementary non-invasive imaging techniques such as dermoscopy and reflectance confocal microscopy (RCM), thus permitting the complete removal of the lesion in a single stage, estimation of the post-excisional defect, and planning an appropriate reconstruction, especially in medical centers where Mohs micrographic surgery is not available. We present the results of a prospective, histopathologically controlled study designed to determine the feasibility of preoperative, non-invasive, in vivo evaluation of the lateral excision margins for primary basal cell carcinoma, through dermoscopy and RCM.

Dual-Wavelength Optical Polarization Imaging for Detecting Skin Cancer Margins

Treatment of keratinocyte carcinomas requires an assessment of the extent of tumor spread. Visual delineation of tumor margins is error-prone owing to the limited contrast between cancerous and normal skin. In this contribution, we introduce spectrally-encoded optical polarization imaging and evaluate its performance for preoperative demarcation of keratinocyte carcinomas. Subjects with basal or squamous cell carcinoma, scheduled for Mohs surgery, were enrolled. The surgeon outlined the clinical boundary of each lesion preoperatively. Optical images of the lesions were then acquired at 440 and 640 nm. Spectral encoding of the experimental images minimized the impact of background pigmentation and vascularization. The surgeon was blinded to the imaging results. Margin assessments by imaging and by the surgeon were recorded and compared with the intraoperative histopathology. In total, 53 lesions were imaged in vivo. Thirteen cases required more than one Mohs stage. In all these cases, images accurately visualized the tumor. For cases negative following the first Mohs stage, margin assessments correlated with histopathology in 39 out of 40 cases. Imaging demonstrated 100% sensitivity and 98% specificity. Spectrally-encoded optical polarization imaging may prove valuable for real-time noninvasive preoperative delineation of skin cancer.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

Evaluation of digital staining for ex vivo confocal laser scanning microscopy

BACKGROUND

Ex vivo confocal laser scanning microscopy (CLSM) is a novel diagnostic tool for the fast examination of native tissue. However, CLSM produces black/white/green images, depending on the refraction indices of the tissue structures, complemented by nuclear fluorescence staining, which the vast majority of Mohs surgeons and dermatopathologists are not trained to interpret. Digital staining is applicable to ex vivo CLSM investigations to simulate the images of conventional slides stained with haematoxylin and eosin (H&E).

OBJECTIVES

The aim of our study was to evaluate in detail the appearance of human skin structures using digitally stained ex vivo CLSM images and compare the results to that of conventional H&E slides of the same specimen.

METHODS

After providing informed consent, 26 patients donated their Burow's triangles (healthy skin) that resulted from plastic reconstruction after the R0 excision of skin tumours. After being investigated by ex vivo CLSM, including automated digital staining (VivaScope 2500M-4G, MAVIG GmbH), the specimens were fixed in formalin, embedded in paraffin and stained with H&E.

RESULTS

Almost all skin structures in the digitally stained ex vivo CLSM images morphologically resembled the structures in the histopathological images acquired from H&E slides. Due to the high refraction index of melanin, the hair shafts appeared bright pink, and the melanocytes and melanophages were poorly imaged, resulting in a strong pink appearance that vastly differed from the appearance of conventional H&E-stained histopathology.

CONCLUSIONS

Digital staining of ex vivo CLSM images is an easy and highly useful tool to facilitate the interpretation of black-field images generated by confocal laser scanning microscopy for dermatopathologists and Mohs surgeons who are familiar with H&E staining. Unlike the pigmented structures, the cutaneous and subcutaneous structures had excellent visualization with only minimal differences from their appearance on H&E slides.

Peri-operative delineation of non-melanoma skin cancer margins in vivo with handheld reflectance confocal microscopy and video-mosaicking

BACKGROUND

The surgical removal of non-melanoma skin cancers (NMSCs) is guided by the pathologic examination of margins. However, the preparation of histopathology is time consuming, labour-intensive and requires separate laboratory infrastructure. Furthermore, when histopathology indicates positive margins, patients must return for re-excisions. Reflectance confocal microscopy (RCM) with a new video-mosaicking approach can noninvasively delineate margins directly on patients and potentially guide surgery in real-time, augmenting the traditional approaches of histopathology.

OBJECTIVE

To assess a new peri-operative RCM video-mosaicking approach for comprehensive delineation of NMSC margins on patients in vivo.

METHODS

Thirty-five patients undergoing Mohs micrographic surgery (MMS) in the Mohs surgery unit at Memorial Sloan Kettering Cancer Center, New York, NY were included in the study. RCM imaging was performed before and after the first staged excision by acquiring videos along the surgical margins (epidermal, peripheral and deep dermal) of each wound, which were subsequently processed into video-mosaics. Two RCM evaluators read and assessed video-mosaics, and subsequently compared to the corresponding Mohs frozen histopathology.

RESULTS

Reflectance confocal microscopy videos and video-mosaics displayed acceptable imaging quality (resolution and contrast), pre-operatively in 32/35 (91%) NMSC lesions and intra-operatively in 29/35 lesions (83%). Pre-operative delineation of margins correlated with the histopathology in 32/35 (91%) lesions. Intra-operative delineation correlated in 10/14 (71%) lesions for the presence of residual tumour and in 18/21 (86%) lesions for absence. Sensitivity/specificity were 71%/86% and 86%/81% for two RCM video-mosaic evaluators, and overall agreement was 80% and 83% with histopathology, with moderate inter-evaluator agreement (k = 0.59, P ≤ 0.0002).

CONCLUSIONS

Peri-operative RCM video-mosaicking of NMSC margins directly on patients may potentially guide surgery in real-time, serve as an adjunct to histopathology, reduce time spent in clinic and reduce the need for re-excisions. Further testing in larger studies is needed.

Emerging imaging technologies in dermatology: Part II: Applications and limitations

Clinical examination is critical for the diagnosis and identification of response to treatment. It is fortunate that technologies are continuing to evolve, enabling augmentation of classical clinical examination with noninvasive imaging modalities. This article discusses emerging technologies with a focus on digital photographic imaging, confocal microscopy, optical coherence tomography, and high-frequency ultrasound, as well as several additional developing modalities. The most readily adopted technologies to date include total-body digital photography and dermoscopy, with some practitioners beginning to use confocal microscopy. In this article, applications and limitations are addressed. For a detailed discussion of the principles involved in these technologies, please refer to the first part of this review article.

Reflectance confocal microscopy as a tool for screening surgical margins of basal cell carcinoma

Surgical excision of basal cell carcinoma with minimum margins requires serial assessment of layers by frozen histopathology in the case of Mohs micrographic surgery. Evaluation of presurgical tumor margins by in vivo reflectance confocal microscopy is a potential alternative. We selected 12 basal cell carcinoma lesions that were analyzed by confocal microscopy to define margins. The lesions were excised by Mohs surgery. Six tumors showed negative margins in the first phase of Mohs micrographic surgery. We concluded that reflectance confocal microscopy can be useful in the preoperative definition of basal cell carcinoma margins.

Hyperspectral imaging system in the delineation of Ill-defined basal cell carcinomas: a pilot study

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer in the Caucasian population. Eighty per cent of BCCs are located on the head and neck area. Clinically ill-defined BCCs often represent histologically aggressive subtypes, and they can have subtle subclinical extensions leading to recurrence and the need for re-excisions.

OBJECTIVES

The aim of this pilot study was to test the feasibility of a hyperspectral imaging system (HIS) in vivo in delineating the preoperatively lateral margins of ill-defined BCCs on the head and neck area.

METHODS

Ill-defined BCCs were assessed clinically with a dermatoscope, photographed and imaged with HIS. This was followed by surgical procedures where the BCCs were excised at the clinical border and the marginal strip separately. HIS, with a 12-cm² field of view and fast data processing, records a hyperspectral graph for every pixel in the imaged area, thus creating a data cube. With automated computational modelling, the spectral data are converted into localization maps showing the tumour borders. Interpretation of these maps was compared to the histologically verified tumour borders.

RESULTS

Sixteen BCCs were included. Of these cases, 10 of 16 were the aggressive subtype of BCC and 6 of 16 were nodular, superficial or a mixed type. HIS delineated the lesions more accurately in 12 of 16 of the BCCs compared to the clinical evaluation (4 of 16 wider and 8 of 16 smaller by HIS). In 2 of 16 cases, the HIS-delineated lesion was wider without histopathological confirmation. In 2 of 16 cases, HIS did not detect the histopathologically confirmed subclinical extension.

CONCLUSIONS

HIS has the potential to be an easy and fast aid in the preoperative delineation of ill-defined BCCs, but further adjustment and larger studies are warranted for an optimal outcome.

Identification of tumor margins using diffuse reflectance spectroscopy with an extended-wavelength spectrum in a porcine model

OBJECTIVE

A novel extended-wavelength diffuse reflectance spectroscopy (EWDRS) technique is being developed for future clinical non-invasive tumor margin delineation. In this study, the ability of EWDRS to identify the margins of pigmented skin lesions in an in vivo pig model was evaluated.

MATERIALS AND METHODS

Extended-wavelength diffuse reflectance spectroscopy recordings (350-1550 nm) were made on 13 pigmented skin lesions and non-pigmented skin, as a reference. The hand-held probe was swept toward the pigmented area until the signal changed, thus indicating that the margin had been identified. A needle was inserted as a marker, and tissue samples were sent for histological analysis. The distance between the EWDRS-defined border and the histological border was measured by 3 independent examiners.

RESULTS

The median difference between the EWDRS-defined border and the histological border was 70 μm toward the pigmented tissue (range: -579 to 538 μm). A Pearson correlation coefficient of .95 was obtained for the examiners.

CONCLUSIONS

Extended-wavelength diffuse reflectance spectroscopy can be used in vivo to delineate the border of pigmented skin lesions in a porcine model with high accuracy, indicating that it may be a useful tool for non-invasive tumor margin delineation in the future.

Peripheral histological clearance of cutaneous BCC and SCC excised using the wet blotting technique

Introduction

Accurate identification of the peripheral margin of cutaneous basal cell and squamous cell carcinomas plays a crucial role in ensuring complete excision of the skin cancer. The recommended margin of excision for cutaneous malignancies varies in the current guidelines. The aim of this study was to assess the success rate of peripheral margin clearance with a 4 mm peripheral margin of excision when the clinical margin of the lesion has been identified using the wet blotting technique.

Methods

The peripheral margin of each skin cancer was marked using the wet blotting technique and a 4-mm margin of excision rule was applied to all skin cancers regardless of their type and other clinical features. Data collection was performed from patients who were operated on over a period of 34 months (2011 to 2014). Information gathered included patient demographics, clinical details of the lesion and histopathological data.

Results

The total number of patients identified were 456. The case notes were reviewed and eventually 276 patients were included and 180 patients were excluded. The histology report showed 95–97% clearance of the peripheral margin in all BCCs and SCCs regardless of their clinical features and their location.

Conclusions

Our study has shown that a standard rule of maintaining a 4 mm margin around all head and neck skin BCCs and SCCs, measured after the visible margin of the lesion had been accurately identified by the wet-blotting technique, can successfully achieve 95–97% peripheral clearance of all lesions, irrespective of the subtype, size and location.

Imaging in cutaneous surgery

Skin cancer is the most commonly diagnosed cancer in the USA. Mohs micrographic surgery is a microscopically controlled surgical technique that excises lateral and deep surgical margins while also sparing function and achieving a good cosmetic outcome. Given the increasing incidence in skin cancer worldwide and its associated treatment costs, techniques are being developed to improve the time and cost efficacy of this procedure. The use of noninvasive imaging, both in vivo and ex vivo, has the potential to increase efficiency of diagnosis and surgical management of skin cancers. These devices are useful in delineating lateral and deep tumor margins prior to surgery in vivo as well as to detect residual tumor ex vivo virtually in real time.

Handheld optical coherence tomography-reflectance confocal microscopy probe for detection of basal cell carcinoma and delineation of margins

We present a hand-held implementation and preliminary evaluation of a combined optical coherence tomography (OCT) and reflectance confocal microscopy (RCM) probe for detecting and delineating the margins of basal cell carcinomas (BCCs) in human skin <italic<in vivo</italic<. A standard OCT approach (spectrometer-based) with a central wavelength of 1310 nm and 0.11 numerical aperture (NA) was combined with a standard RCM approach (830-nm wavelength and 0.9 NA) into a common path hand-held probe. Cross-sectional OCT images and enface RCM images are simultaneously displayed, allowing for three-dimensional microscopic assessment of tumor morphology in real time. Depending on the subtype and depth of the BCC tumor and surrounding skin conditions, OCT and RCM imaging are able to complement each other, the strengths of each helping overcome the limitations of the other. Four representative cases are summarized, out of the 15 investigated in a preliminary pilot study, demonstrating how OCT and RCM imaging may be synergistically combined to more accurately detect BCCs and more completely delineate margins. Our preliminary results highlight the potential benefits of combining the two technologies within a single probe to potentially guide diagnosis as well as treatment of BCCs.

In Vivo and Ex Vivo Confocal Microscopy for Dermatologic and Mohs Surgeons

Confocal microscopy is a modern imaging device that has been extensively applied in skin oncology. More specifically, for tumor margin assessment, it has been used in two modalities: reflectance mode (in vivo on skin patient) and fluorescence mode (on freshly excised specimen). Although in vivo reflectance confocal microscopy is an add-on tool for lentigo maligna mapping, fluorescence confocal microscopy is far superior for basal cell carcinoma and squamous cell carcinoma margin assessment in the Mohs setting. This article provides a comprehensive overview of the use of confocal microscopy for skin cancer margin evaluation.

Assessment of skin pigmentation by confocal microscopy: Influence of solar exposure and protection habits on cutaneous hyperchromias

BACKGROUND

Cutaneous hyperchromias are disorders of skin pigmentation involving an increase of melanin production and its irregular accumulation in skin cells. It is known that the use of sunscreens helps to prevent changes in the skin pigmentation pattern, but the structural and morphological alterations that occur in the different types of hyperpigmentations need better elucidation.

OBJECTIVE

To assess the influence of solar exposure and protection habits on the pattern of skin pigmentation using reflectance confocal microscopy (RCM).

METHODS

Forty volunteers aged 18-39 years with skin hyperpigmentation participated in the study. Skin characterization was performed by imaging techniques and by assessing the habits of solar exposure and protection by applying questionnaires to the volunteers. RCM was used to record sequences of confocal sections at areas of interest and to examine cell shape and brightness in the basal cell layer of the lesion and in normal perilesional skin. Furthermore, high-resolution images were obtained for analysis of the spots.

RESULTS

Sunlight influences the number and location of spots as the face of volunteers with higher solar exposure was covered with spots, whereas volunteers with less exposure had fewer spots located in the nose and cheeks region due to greater exposure of these areas to the sun.

CONCLUSION

The data showed the importance of sun protection for preventing changes in the pattern of skin pigmentation, and RCM proved to be an important tool for skin characterization.

Reflectance confocal microscopy of skin in vivo: From bench to bedside

Following more than two decades of effort, reflectance confocal microscopy (RCM) imaging of skin was granted codes for reimbursement by the US Centers for Medicare and Medicaid Services. Dermatologists in the USA have started billing and receiving reimbursement for the imaging procedure and for the reading and interpretation of images. RCM imaging combined with dermoscopic examination is guiding the triage of lesions into those that appear benign, which are being spared from biopsy, against those that appear suspicious, which are then biopsied. Thus far, a few thousand patients have been spared from biopsy of benign lesions. The journey of RCM imaging from bench to bedside is certainly a success story, but still much more work lies ahead toward wider dissemination, acceptance, and adoption. We present a brief review of RCM imaging and highlight key challenges and opportunities. The success of RCM imaging paves the way for other emerging optical technologies, as well-and our bet for the future is on multimodal approaches. Lasers Surg. Med. 49:7-19, 2017. © 2016 Wiley Periodicals, Inc.

Master/slave optical coherence tomography imaging of eyelid basal cell carcinoma

Optical coherence tomography (OCT) is fast emerging as an additional non-interventional modality for skin tumor detection and diagnosis. A master/slave flying spot OCT configuration was assembled to detect periocular basal cell carcinomas (BCC). A swept source at 1300 nm and sweeping speed of 50 kHz were used. A three-step process was involved. First, 384 channeled spectra using a mirror were stored for 384 optical path differences at the master stage. Then, the stored channeled spectra (masks) were correlated with the channeled spectrum from the BCC tissue to produce 384 en face OCT images (200×200 pixels) for the optical path difference values used to acquire the masks. Finally, these en face slices were stacked to form a volume to cross-reference BCC tumor margins in the orthogonal plane. Per each eyelid sample, several en face images of 200×200 lateral pixels are produced in the time to scan laterally a complete raster of 1.6 s. Combination of the en face views with the cross-sectioning views allow for better discrimination of BCCs comparable to using cross-sectional imaging alone, as previously reported using the conventional fast-Fourier-transform-based OCT techniques.

[Therapy of basal cell carcinoma]

Basal cell carcinoma (BCC) represents the most common malignant skin tumour in fair-skinned people. Despite low metastatic potential, BCC can cause decisive tissue destruction and disfigurement by invasive growth. In addition to clinical and histologic diagnosis modern imaging techniques as optical coherence tomography and confocal laser microscopy have been introduced. BCCs with aggressive growth pattern and/or increased risk of relapse are preferentially treated surgically. For superficial BCCs various topical treatments and photodynamic therapy are available. Inhibitors of the sonic hedgehog pathway have been approved for symptomatic treatment of metastatic BCC and locally advanced BCC inappropriate for surgery or radiotherapy. Detailed knowledge of the clinical spectrum of BCC and an appropriate choice of therapy are mandatory for the successful treatment of BCC.