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Danescu S, Negrutiu M, Focsan M, Baican A. An overview of cutaneous squamous cell carcinoma imaging diagnosis methods. Front Med (Lausanne) 2024; 11:1388835. [PMID: 38737758 PMCID: PMC11084285 DOI: 10.3389/fmed.2024.1388835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024] Open
Abstract
Cutaneous squamous cell carcinoma, a type of non-melanoma skin cancer, is a form of keratinocyte carcinoma that stands as one of the most prevalent cancers, exhibiting a rising frequency. This review provides an overview of the latest literature on imaging methods for diagnosing squamous cell carcinoma (SCC) and actinic keratosis (AK). It discusses the diagnostic criteria, advantages, and disadvantages of various techniques such as dermatoscopy, skin ultrasound (US), in vivo and ex-vivo reflectance confocal microscopy (RCM), and line-field confocal optical coherence tomography (LC-OCT). These methods offer benefits including non-invasiveness, rapidity, comprehensive lesion imaging, and enhanced sensitivity, but face challenges like high costs and the need for specialized expertise. Despite obstacles, the use of these innovative techniques is expected to increase with ongoing technological advancements, improving diagnosis and treatment planning for keratinocyte carcinomas. Standardizing LC-OCT imaging algorithms for AK, Bowen's disease, and SCC remains an area for further research.
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Affiliation(s)
- Sorina Danescu
- Department of Dermatology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mircea Negrutiu
- Department of Dermatology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Monica Focsan
- Nanobiophotonics and Laser Microspectroscopy Center, Interdisciplinary Research Institute on Bio-Nano-Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
- Biomolecular Physics Department, Faculty of Physics, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Adrian Baican
- Department of Dermatology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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2
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Crisan D, Tarnowietzki E, Bernhard L, Möller M, Scharffetter-Kochanek K, Crisan M, Schneider LA. Rationale for Using High-Frequency Ultrasound as a Routine Examination in Skin Cancer Surgery: A Practical Approach. J Clin Med 2024; 13:2152. [PMID: 38610917 PMCID: PMC11012407 DOI: 10.3390/jcm13072152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Ultrasound and high-frequency ultrasound assessment of melanoma and non-melanoma skin cancer in the pre-therapeutical setting is becoming increasingly popular in the field of dermatosurgery and dermatooncology, as it can provide clinicians with relevant, "in vivo" parameters regarding tumor lateral and depth extension as well as potential locoregional spread, cancelling the need of more extensive imaging methods and avoiding a delay in diagnosis. Furthermore, preoperative sonography and color Doppler can aid in orienting the clinical diagnosis, being able in numerous situations to differentiate between benign and malignant lesions, which require a different therapeutic approach. This preoperative knowledge is of paramount importance for planning an individualized treatment regimen. Using sonography at the time of diagnosis, important surgical complications, such as neurovascular damage, can be avoided by performing a preoperative neurovascular mapping. Furthermore, sonography can help reduce the number of surgical steps by identifying the lesions' extent prior to surgery, but it can also spare unnecessary surgical interventions in cases of locally advanced lesions, which infiltrate the bone or already present with locoregional metastases, which usually require modern radiooncological therapies in accordance to European guidelines. With this review, we intend to summarize the current indications of sonography in the field of skin cancer surgery, which can help us improve the therapeutic attitude toward our patients and enhance patient counseling. In the era of modern systemic radiooncological therapies, sonography can help better select patients who qualify for surgical procedures or require systemic treatments due to tumoral extension.
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Affiliation(s)
- Diana Crisan
- Clinic of Dermatology and Allergology, University Clinic Ulm, 89081 Ulm, Germany
| | - Evelyne Tarnowietzki
- Clinic of Dermatology and Allergology, University Clinic Ulm, 89081 Ulm, Germany
| | - Lukas Bernhard
- Clinic of Dermatology and Allergology, University Clinic Ulm, 89081 Ulm, Germany
| | - Melina Möller
- Clinic of Dermatology and Allergology, University Clinic Ulm, 89081 Ulm, Germany
| | | | - Maria Crisan
- Department of Dermatology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
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3
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Liu ZF, Chew CY, Honavar S, Maxwell A, Sylivris A, Sheridan A. Seeing beyond skin deep: High-resolution ultrasound in dermatology-A comprehensive review and future prospects. J Eur Acad Dermatol Venereol 2024. [PMID: 38426546 DOI: 10.1111/jdv.19939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024]
Abstract
High-resolution ultrasound (HRUS), operating at frequencies of 20-25 MHz, is a non-invasive imaging tool that offers dermatologists the ability to visualize structures beneath the skin surface. The objective of this review is to present a comprehensive overview of HRUS applications, emphasising its utility in diagnosing, characterising and managing various dermatological conditions. We undertook a comprehensive literature review on the dermatological application of HRUS across Medline, Embase and Cochrane Library databases, while also incorporating our own clinical experience of over 16 years with the tool. In normal skin, the epidermis and dermis are hyperechoic, and the subcutaneous layer is hypoechoic. Basal cell carcinomas appear hypoechoic with irregular margins, while the presence of hyperechoic inclusion bodies suggests aggressive pathology. Squamous cell carcinomas pose challenges due to acoustic shadow artefacts from the thickened stratum corneum. Melanomas are homogenous hypoechoic lesions, with HRUS used to accurately predict Breslow thickness. HRUS provides dermatologists with a valuable adjunct to traditional clinical examination. Future advancement in image resolution and the standardisation of diagnostic parameters may further expand its utility.
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Affiliation(s)
| | - Christopher Y Chew
- The Alfred Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shreyas Honavar
- Faculty of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maxwell
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amy Sylivris
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam Sheridan
- The Alfred Hospital, Melbourne, Victoria, Australia
- Specialist Dermatology, Surgery & Laser, Melbourne, Victoria, Australia
- Specialist Dermatology, Surgery & Laser, Adelaide, South Australia, Australia
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4
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Russo GM, Russo A, Urraro F, Cioce F, Gallo L, Belfiore MP, Sangiovanni A, Napolitano S, Troiani T, Verolino P, Sica A, Brancaccio G, Briatico G, Nardone V, Reginelli A. Management of Non-Melanoma Skin Cancer: Radiologists Challenging and Risk Assessment. Diagnostics (Basel) 2023; 13:diagnostics13040793. [PMID: 36832281 PMCID: PMC9955870 DOI: 10.3390/diagnostics13040793] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma are the three main types of nonmelanoma skin cancers and their rates of occurrence and mortality have been steadily rising over the past few decades. For radiologists, it is still difficult to treat patients with advanced nonmelanoma skin cancer. Nonmelanoma skin cancer patients would benefit greatly from an improved diagnostic imaging-based risk stratification and staging method that takes into account patient characteristics. The risk is especially elevated among those who previously received systemic treatment or phototherapy. Systemic treatments, including biologic therapies and methotrexate (MTX), are effective in managing immune-mediated diseases; however, they may increase susceptibility to NMSC due to immunosuppression or other factors. Risk stratification and staging tools are crucial in treatment planning and prognostic evaluation. PET/CT appears more sensitive and superior to CT and MRI for nodal and distant metastasis as well as in surveillance after surgery. The patient treatment response improved with advent and utilization of immunotherapy and different immune-specific criteria are established to standardized evaluation criteria of clinical trials but none of them have been utilized routinely with immunotherapy. The advent of immunotherapy has also arisen new critical issues for radiologists, such as atypical response pattern, pseudo-progression, as well as immune-related adverse events that require early identification to optimize and improve patient prognosis and management. It is important for radiologists to have knowledge of the radiologic features site of the tumor, clinical stage, histological subtype, and any high-risk features to assess immunotherapy treatment response and immune-related adverse events.
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Affiliation(s)
- Gaetano Maria Russo
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
- Correspondence:
| | - Anna Russo
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Fabrizio Urraro
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Fabrizio Cioce
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Luigi Gallo
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Maria Paola Belfiore
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Stefania Napolitano
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Teresa Troiani
- Unit of Plastic Surgery, Multidisciplinary Department of Medical Surgical and Dental Specialties, University of Campania “Luigi Vanvitelli”, 80120 Naples, Italy
| | - Pasquale Verolino
- Unit of Plastic Surgery, Multidisciplinary Department of Medical Surgical and Dental Specialties, University of Campania “Luigi Vanvitelli”, 80120 Naples, Italy
| | - Antonello Sica
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Gabriella Brancaccio
- Unit of Dermatology, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Giulia Briatico
- Unit of Dermatology, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Valerio Nardone
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy
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Zhang X, Shi J, Sun Z, Dai T. The diagnostic value of imaging techniques for keratoacanthoma: A review. Medicine (Baltimore) 2022; 101:e32097. [PMID: 36596022 PMCID: PMC9803432 DOI: 10.1097/md.0000000000032097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Keratoacanthoma (KA) is a fast-growing skin tumor with solitary KA being the most common type. KAs rarely metastasize and subside spontaneously. Although histopathology is the gold standard for the diagnosis of KA, its histopathological features are sometimes difficult to distinguish from those of other skin tumors. Imaging studies have certain advantages in the preoperative diagnosis of KA; they not only show the exact shape of the lesion but can also accurately determine the extent of the lesion. Combined with histopathological examination, these findings help establish a diagnosis. By summarizing the imaging features of KA, this article aimed to improve radiologists' understanding of the disease and help in the clinical and differential diagnosis of KA.
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Affiliation(s)
- Xiujuan Zhang
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jiahong Shi
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Zhixia Sun
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
- * Correspondence: Zhixia Sun, Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province 130033, China (e-mail: )
| | - Ting Dai
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
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High-Definition Ultrasound Characterization of Squamous Carcinoma of the Tongue: A Descriptive Observational Study. Cancers (Basel) 2022; 14:cancers14030564. [PMID: 35158831 PMCID: PMC8833637 DOI: 10.3390/cancers14030564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary The application of high-frequency ultrasound in the oral cavity for malignant lesions is a growing trend. As with other parts of the body, this method could become routine in the future. With this in mind, this work aimed to characterize squamous tumors of the tongue ultrasonographically and added additional descriptive elements to the current literature. Abstract High-definition ultrasonography is a diagnostic tool that uses sound echoes to produce images of tissues and organs. In the head and neck region, ultrasounds have been used to diagnose different types of lesions. The intraoral approach was shown to be a real-time, non-invasive way to characterize oral lesions. The tongue is the most often examined region because of its accessibility. This observational study aimed to describe the qualitative characteristics of tongue squamous cell carcinoma images obtained with high-definition intraoral ultrasound by comparing them with the corresponding histopathological sample. Twenty patients were enrolled in this study. The scans of the lesions were carried out with an 18 MHz linear ultrasound probe following the long axis of the lesion. For each lesion, five frames were selected, on which descriptive analysis was performed. A histological sample was taken and then compared to the ultrasonographic acquisition. The sonographic appearance of the tissue layers has a good correlation between ultrasound and histological morphology, and it was easy to distinguish the tumor from the homogenous composition of the tongue tissues. Furthermore, a correlation between the structure by section and pattern of tumor margin features by ultrasound was obtained. Intraoral ultrasonography appears to be a promising technique in the non-invasive characterization of tongue squamous cell carcinoma. Further studies will be needed to improve the technique in terms of ergonomics and repeatability.
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Chen ZT, Yan JN, Zhu AQ, Wang LF, Wang Q, Li L, Guo LH, Li XL, Xu HX. High-frequency ultrasound for differentiation between high-risk basal cell carcinoma and cutaneous squamous cell carcinoma. Skin Res Technol 2021; 28:410-418. [PMID: 34923684 PMCID: PMC9907640 DOI: 10.1111/srt.13121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 10/16/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The similar visual appearance of high-risk basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) may cause confusion for diagnosis. High-frequency ultrasound (HFUS) may provide additional intralesional information and thus help to distinguish them. METHOD In this retrospective study, we analyzed the clinical characteristics, HFUS grayscale, and color Doppler flow imaging (CDFI) features of pathologically confirmed high-risk BCC and cSCC lesions (n = 65 vs n = 68). Subsequently, discrimination models based on the significant HFUS features were established. RESULTS Between high-risk BCC and cSCC lesions, the HFUS grayscale features of the lesion size (10.0 mm vs 17.4 mm), thickness (3.1 mm vs 5.9 mm), internal hyperechoic spots (80.0% vs 23.5%), and posterior acoustic shadowing (16.9% vs 66.2%) were statistically different (all p < 0.001). As for the CDFI features, high-risk BCC lesions mainly appeared as pattern II (47.7%), while cSCC lesions mainly appeared as pattern III (66.2%). Based on the above five features, an optimal discrimination model was established with a sensitivity of 91.2%, a specificity of 87.7%, and an accuracy of 89.5%. CONCLUSION HFUS features, including size, thickness, internal hyperechoic spots, posterior acoustic shadowing, and Doppler vascularity pattern, are useful for differential diagnosis between high-risk BCC and cSCC.
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Affiliation(s)
- Zi-Tong Chen
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jian-Na Yan
- Department of Dermatologic Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - An-Qi Zhu
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Li-Fan Wang
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Qiao Wang
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Liang Li
- Department of Dermatologic Surgery, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Le-Hang Guo
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Xiao-Long Li
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Hui-Xiong Xu
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, Ultrasound Research and Education Institute, School of Medicine, Tongji University, Shanghai, China.,Center of Minimally Invasive Treatment for Tumor, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, National Clinical Research Center for Interventional Medicine, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, China
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Jung JM, Cho JY, Lee WJ, Chang SE, Lee MW, Won CH. Emerging Minimally Invasive Technologies for the Detection of Skin Cancer. J Pers Med 2021; 11:951. [PMID: 34683091 PMCID: PMC8538732 DOI: 10.3390/jpm11100951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/23/2022] Open
Abstract
With the increasing incidence of skin cancer, many noninvasive technologies to detect its presence have been developed. This review focuses on reflectance confocal microscopy (RCM), optical coherence tomography (OCT), high-frequency ultrasound (HFUS), electrical impedance spectroscopy (EIS), pigmented lesion assay (PLA), and Raman spectroscopy (RS) and discusses the basic principle, clinical applications, advantages, and disadvantages of each technology. RCM provides high cellular resolution and has high sensitivity and specificity for the diagnosis of skin cancer. OCT provides lower resolution than RCM, although its evaluable depth is deeper than that of RCM. RCM and OCT may be useful in reducing the number of unnecessary biopsies, evaluating the tumor margin, and monitoring treatment response. HFUS can be mainly used to delineate tumor depths or margins and monitor the treatment response. EIS provides high sensitivity but low specificity for the diagnosis of skin malignancies. PLA, which is based on the genetic information of lesions, is applicable for the detection of melanoma with high sensitivity and moderate-to-high specificity. RS showed high accuracy for the diagnosis of skin cancer, although more clinical studies are required. Advances in these technologies for the diagnosis of skin cancer can lead to the realization of optimized and individualized treatments.
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Affiliation(s)
- Joon Min Jung
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.M.J.); (W.J.L.); (S.E.C.); (M.W.L.)
| | - Ji Young Cho
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea;
| | - Woo Jin Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.M.J.); (W.J.L.); (S.E.C.); (M.W.L.)
| | - Sung Eun Chang
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.M.J.); (W.J.L.); (S.E.C.); (M.W.L.)
| | - Mi Woo Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.M.J.); (W.J.L.); (S.E.C.); (M.W.L.)
| | - Chong Hyun Won
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.M.J.); (W.J.L.); (S.E.C.); (M.W.L.)
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