2021 international consensus statement on optical coherence tomography for basal cell carcinoma: image characteristics, terminology and educational needs

BACKGROUND

Despite the widespread use of optical coherence tomography (OCT) for imaging of keratinocyte carcinoma, we lack an expert consensus on the characteristic OCT features of basal cell carcinoma (BCC), an internationally vetted set of OCT terms to describe various BCC subtypes, and an educational needs assessment.

OBJECTIVES

To identify relevant BCC features in OCT images, propose terminology based on inputs from an expert panel and identify content for a BCC-specific curriculum for OCT trainees.

METHODS

Over three rounds, we conducted a Delphi consensus study on BCC features and terminology between March and September 2020. In the first round, experts were asked to propose BCC subtypes discriminable by OCT, provide OCT image features for each proposed BCC subtypes and suggest content for a BCC-specific OCT training curriculum. If agreement on a BCC-OCT feature exceeded 67%, the feature was accepted and included in a final review. In the second round, experts had to re-evaluate features with less than 67% agreement and rank the ten most relevant BCC OCT image features for superficial BCC, nodular BCC and infiltrative and morpheaphorm BCC subtypes. In the final round, experts received the OCT-BCC consensus list for a final review, comments and confirmation.

RESULTS

The Delphi included six key opinion leaders and 22 experts. Consensus was found on terminology for three OCT BCC image features: (i) hyporeflective areas, (ii) hyperreflective areas and (iii) ovoid structures. Further, the participants ranked the ten most relevant image features for nodular, superficial, infiltrative and morpheaform BCC. The target group and the key components for a curriculum for OCT imaging of BCC have been defined.

CONCLUSION

We have established a set of OCT image features for BCC and preferred terminology. A comprehensive curriculum based on the expert suggestions will help implement OCT imaging of BCC in clinical and research settings.

Line-field confocal optical coherence tomography for the in vivo real-time diagnosis of different stages of keratinocyte skin cancer: a preliminary study

BACKGROUND

The treatment of keratinocyte cancers (KC) strictly depends on their differentiation and invasiveness. Non-invasive diagnostic techniques can support the diagnosis in real time, avoiding unnecessary biopsies. This study aimed to preliminarily define main imaging criteria and histological correlations of actinic keratosis (AK), Bowen's disease (BD) and squamous cell carcinoma (SCC) using the novel device line-field confocal optical coherence tomography (LC-OCT).

METHODS

Dermoscopy and LC-OCT images of 73 histopathologically confirmed lesions (46 AKs, 11 BD and 16 SCCs) were included in the study. Exemplary lesions (10 AKs, 5 BD and 5 SCCs) were additionally investigated with optical coherence tomography and reflectance confocal microscopy.

RESULTS

Most common LC-OCT findings of KC in the descriptive statistics were hyperkeratosis/parakeratosis, disruption of stratum corneum, broadened epidermis, basal and suprabasal keratinocyte atypia, dilated vessels/neoangiogenesis and elastosis/collagen alterations. In the univariate multinomial logistic regression, a preserved DEJ was less common in SCC compared with AK and BD, BD displayed marked keratinocyte atypia involving all epidermal layers (bowenoid pattern), while SCC showed ulceration, increased epidermal thickness, keratin plugs, acantholysis, not visible/interrupted DEJ and epidermal bright particles. LC-OCT increased the diagnostic confidence by 24.7% compared with dermoscopy alone.

CONCLUSIONS

Our study describes for the first time specific LC-OCT features of different stages of KC and their histopathological correlates, focusing on keratinocyte morphology and architecture of the epidermis and DEJ. LC-OCT may open new scenarios in the bedside diagnosis, treatment planning and follow-up of KC.

Line-field optical coherence tomography: In vivo diagnosis of basal cell carcinoma subtypes compared to histopathology

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer in the general population. Treatments vary from Mohs surgery to topical therapy, depending on the subtype. Dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) have gained a foothold in daily clinical practice to optimize diagnosis and subtype-oriented treatment. The new device Line-field confocal OCT (LC-OCT) allows imaging at high resolution and depth but its use is not yet been investigated in larger studies.

OBJECTIVES

To evaluate the main LC-OCT criteria for the diagnosis and subtyping of BCC in comparison to histopathology, OCT and RCM.

METHODS

Fifty-two histopathologically confirmed BCCs were evaluated for imaging criteria. Their frequency, predictive values and ROC curves were calculated. A multinominal regression with stepwise variables selection to distinguish BCC subtypes was performed.

RESULTS

Nodular BCCs were mainly characterized by atypical keratinocytes, altered DEJ, tumour nests in the dermis, dark clefting, prominent vascularisation and white hyperreflective stroma. Superficial BCCs showed a thickening of the epidermis due to a series of tumour lobules with clear connection to the DEJ (string of pearls pattern). Infiltrative BCCs were characterized by elongated hyporeflective tumour strands, surrounded by bright collagen (shoal of fish). The overall BCC subtype agreement between LC-OCT and conventional histology was 90.4 % (95% CI: 79.0, 96.8).

CONCLUSION

LC-OCT allows the non-invasive, real time identification of BCCs and their subtypes in vertical, horizontal and 3D mode compared to histology, RCM and OCT. Further larger studies are needed to better explore the clinical applications of this promising device.

Struktur der Hautkliniken und dermatologische Lehre in den neuen Universitäten in Deutschland

Im Zuge der Neugründung medizinischer Fakultäten in Deutschland muss auch die dermatologische Forschung und Lehre aufgebaut werden. Diese großen Zusatzaufgaben neben der Krankenversorgung stellen eine Herausforderung für die Klinikleitungen dar. In diesem Übersichtsbeitrag beschreiben exemplarisch Chefärztinnen und Chefärzte neuer Universitätshautkliniken und dermatologischer Fachabteilungen die Auswirkungen, die die Umwandlung in eine Universitätsklinik auf die Forschung und Lehre sowie den klinischen Alltag mit sich gebracht hat.

Wie wird man Uniklinikum? Neue Wege des Medizinstudiums in Deutschland

Die Nachfrage nach Studienplätzen der Humanmedizin übersteigt seit vielen Jahren deutlich das Angebot der staatlichen Medizinfakultäten in Deutschland. Durch den zunehmenden Ärztemangel steigt auf der anderen Seite der Bedarf an ausgebildeten Medizinerinnen und Medizinern. Um diese Lücke zu schließen, wurden in den letzten Jahren zahlreiche Möglichkeiten neu eröffnet, in Deutschland Humanmedizin zu studieren. Neben Neugründungen von Fakultäten sind insbesondere Kooperationen von Kliniken mit europäischen Universitäten und Privatuniversitäten zu nennen. Dieser Beitrag gibt eine Übersicht über die Optionen und Rahmenbedingungen.

[Noninvasive diagnostic imaging in pediatric skin lesions]

Optical coherence tomography (OCT) and reflectance confocal laser microscopy (RCM) allow noninvasive imaging diagnostics of the skin. Since the indication for a biopsy in children is generally made cautiously, OCT and KLM can be helpful in the clarification of pediatric skin lesions. In addition, biopsies only represent a snapshot of a small area of the skin, while noninvasive methods allow several locations to be examined over time, so that dynamic changes and the course of therapy can also be determined. In pediatric dermatology, these diagnostic methods are particularly suitable for the clarification of atypical pigment lesions, for infectious dermatoses such as scabies or tinea, and for the diagnosis of inflammatory and degenerative dermatoses.

Dynamic optical coherence tomography shows characteristic alterations of blood vessels in malignant melanoma

BACKGROUND

Dynamic optical coherence tomography (D-OCT) allows in vivo visualization of blood vessels in the skin and in malignant tumours. Vessel patterns in malignant melanoma may be associated with tumour stage.

OBJECTIVE

The aim of this study was to describe blood vessel patterns in melanomas and to correlate them with stage.

METHODS

One hundred fifty-nine malignant melanomas were assessed in a multicentre study. Every tumour was imaged using D-OCT prior to surgery and histologic evaluation. The tumour data such as thickness and ulceration as well as the staging at primary diagnosis and a follow-up of at least 40 months resulted in a stage classification. The vessel patterns were assessed according to predefined categories, compared with healthy adjacent skin, and correlated to stage.

RESULTS

Melanomas contained more blood vessels in different patterns compared with healthy adjacent skin. In particular, irregular vascular shapes such as blobs, coils, curves and serpiginous vessels were more common in melanomas. In addition, these patterns were significantly more often found in high-risk and metastatic melanomas than in low-risk lesions.

CONCLUSION

In melanomas, the density of the blood vessels is increased, and irregular vascular patterns are more frequent. At higher stages, especially in metastatic melanomas, these atypical vessels are significantly more common.

Quantitative ion determination in eccrine sweat gland cells correlates to sweat reduction of antiperspirant actives

OBJECTIVE

Axillary wetness represents an unwanted effect of the physiologically vital sweating mechanism, especially when it becomes excessive. Cosmetic products reducing sweat secretion rely on aluminium salts as the active ingredient acting by physically blocking the sweat gland. Driven by the interest to better understand the sweat mechanism and to develop alternative technologies against excessive sweating a search for an effective testing approach started as up to now, cost- and time-consuming in vivo studies represent the standard procedure for testing and identifying these alternatives.

MATERIAL AND METHODS

The herein described in vitro test system is based on the measurement of intracellular changes of the ion equilibrium in cultured eccrine sweat gland cells. Subsequently, in vivo studies on the back of volunteers were conducted to verify the sweat-reducing effect of in vitro newly discovered substance.

RESULTS

In this study, we describe an effective cell-based in vitro method as a potent tool for a more targeted screening of alternatives to aluminium salts. Testing the commonly used aluminium chlorohydrate as one example of an aluminium-based active in this screening procedure, we discovered a distinct influence on the ion equilibrium: Intracellular levels of sodium ions were decreased while those of chloride increased. Screening of various substances revealed a polyethyleneimine, adjusted to pH 3.5 with hydrochloric acid, to evoke the same alterations in the ion equilibrium as aluminium chlorohydrate. Subsequent in vivo studies showed its substantial antiperspirant action and confirmed the high efficiency of the polyethyleneimine solution in vivo. Further, specific investigations connecting the chloride content of the tested substances with the resulting sweat reduction pointed towards a substantial impact of the chloride ions on sweating.

CONCLUSION

The newly described in vitro cell-based screening method represents an effective means for identifying new antiperspirant actives and suggests an additional biological mechanism of action of sweat-reducing ingredients which is directed towards unbalancing of the ion equilibrium inside eccrine sweat gland cells.

„Pilze suchen – was hilft?“

Pilzinfektionen verursachen häufig eine Entzündung der Haut, die je nach Erreger und Lokalisation unterschiedlich stark ist. Diese Beobachtung kann bei der Auswahl der antimykotischen Therapie eine Hilfe sein.

Durch den Einsatz nichtinvasiver Geräte wie der Dermatoskopie, konfokalen Lasermikroskopie (KLM), optischen Kohärenztomografie (OCT) und dynamischen optischen Kohärenztomografie (D-OCT) gelingt eine Darstellung der Haut und auch ihrer Veränderungen bei entzündlichen Mykosen.

Dynamische OCT − was verraten uns die Gefäße?

Die Weiterentwicklung der optischen Kohärenztomografie (OCT) zur dynamischen OCT (D-OCT) erlaubt die gleichzeitige Darstellung der oberflächlichen Blutgefäße. Blut ist das wichtigste Transportsystem unseres Körpers, und sowohl durch äußere als auch durch innere Einflüsse können physiologische Prozesse beeinträchtigt werden. Die D-OCT ermöglicht erstmals die Darstellung dieser Veränderungen anhand der Gefäßdichte und Durchblutung. Durch wiederholtes schnelles Messen der gleichen untersuchten Region können mithilfe einer speziellen Software Unterschiede in einer Bildserie erfasst werden und so sich bewegende Teilchen, die den Blutbestandteilen entsprechen, bis zu einer Tiefe von 0,5 mm vom statischen Hautgewebe differenziert werden. Die Software bildet den Blutfluss im D-OCT-Bild in roter Farbe als Überlagerung über das grau-weiß strukturelle Gewebe ab. Mithilfe der D-OCT konnten physiologische Einflüsse auf die Durchblutung, wie Vasokonstriktion und Positionsänderung, Unterschiede aufgrund der anatomischen Körperregionen, aber auch therapeutische Effekte, wie z. B. durch die lokale Behandlung mit vasokonstringierendem Brimonidin-Gel (einem selektiven α2-Adrenorezeptor-Agonisten) oder bei der Lasertherapie nachgewiesen werden. Weiterhin fanden sich bestimmte Blutgefäßformen nur bei chronisch venösen Ulzera (wie Knäuel am Wundrand oder geschlängelte Gefäße bei Dermatosklerose), während die Blutgefäße bei akuten Wunden eine Häufung von anderen Gefäßformen und Verteilungsmustern zeigten. Bei ausgewählten entzündlichen und autoimmunbedingten Erkrankungen konnten die damit einhergehenden vaskulären Prozesse exemplarisch dargestellt werden. Auch ließ sich mit der D-OCT feststellen, dass eine erhöhte Blutgefäßdichte und gewisse Formen erst mit einer größeren Tumordicke von Melanomen (Breslow-Index) einhergehen. Außerdem können die Blutgefäße zur Differenzierung sowie zur Therapieauswahl von nicht-melanozytärem Hautkrebs beitragen. Die D-OCT ist jedoch nicht nur ein diagnostisches Gerät, sondern eignet sich auch zur bildgeführten Therapie wie der D-OCT-geführten Lasertherapie.

Die D-OCT bietet durch die Darstellung von Blutgefäßen zahlreiche diagnostische und therapeutische Einsatzmöglichkeiten. Die Blutgefäße verraten uns so viel über physiologische und pathologische Prozesse in unserer Haut, und ihre Darstellung wird in Zukunft eine individuellere, patienten-orientiertere Therapie erlauben, als es bisher möglich ist. So könnten z. B. Ulzera verschiedener Genese mittels D-OCT differenziert werden oder Melanome anhand der Gefäßmuster bereits präoperativ risikostratifiziert werden.

„Ein Unglück kommt selten allein …“

Die nichtinvasiven Geräte wie die optische Kohärenztomografie (OCT) und die konfokale Lasermikroskopie (KLM) sind bei der Diagnostik und Therapieauswahl vieler Erkrankungen z. B. von nichtmelanozytärem Hautkrebs sehr hilfreich. Ihr Einsatz eignet sich insbesondere dann, wenn differenzialdiagnostisch mehrere Diagnosen infrage kommen, die eine die andere Erkrankung verschleiert oder ein tieferer nichtinvasiver Blick in die Haut nötig wird.

Wir berichten über den Fall einer 89-jährigen Patientin mit Stevens-Johnson-Syndrom (SJS) nach Einnahme von Allopurinol aufgrund von Hyperurikämie und Gicht. Mit der OCT und KLM können erstmals die Charakteristika beider gemeinsam vorliegender Erkrankungen in vivo dargestellt werden.

Evaluation of two histological classifications for actinic keratoses - PRO classification scored highest inter-rater reliability

BACKGROUND

Actinic keratoses (AKs) can histologically be classified by the extent of atypical keratinocytes throughout the epidermis or their pattern of basal proliferation. Currently, no data on the inter-rater reliability of both scores is available.

OBJECTIVE

To evaluate the inter-rater reliability of the two classification schemes; histological grade (AK I-III) and basal proliferation (PRO I-III).

METHODS

Histological images of 54 AKs were classified by 21 independent dermatopathologists with regard to basal proliferation (PRO I-III), histological grade (AK I-III) and assumed risk of progression into invasive carcinoma.

RESULTS

Overall, of the 54 AKs 16.7% (9/54) were classified as AK I, 66.7% (36/54) as AK II, and 16.7% (9/54) as AK III. With regards to basal growth pattern, 25.9% (14/54) were classified as PRO I, 42.6% (23/54) as PRO II, and 31.5% (17/54) as PRO III. We observed a highly significant inter-rater reliability for PRO-grading (P < 0.001) which was higher than for AK-grading (Kendall's W coefficient: AK = 0.488 vs. PRO = 0.793). We found substantial agreement for assumed progression risk for AKs with worsening basal proliferation (k = 0.759) compared to moderate agreement (k = 0.563) for different AK-gradings.

CONCLUSIONS

Histological classification of basal growth pattern (PRO) showed higher inter-rater reliability compared to the established classification of atypical keratinocytes throughout epidermal layers. Moreover, experienced dermatopathologists considered basal proliferation to be more important in terms of progression risk than upwards directed growth patterns. It should be considered to classify AKs according to their basal proliferation pattern (PRO I-III).

Langerhanszell-Histiozytose unter dem Bild einer Folliculitis decalvans und Intertrigo

Die Langerhanszell-Histiozytose ist eine seltene Erkrankung unklarer Ätiologie, die durch eine Proliferation histiozytärer Zellen in verschiedenen Geweben gekennzeichnet ist. Vor wenigen Jahren wurde entdeckt, dass ein Großteil der LCH-Zellen eine BRAF-Mutation aufweist. Eine neoplastische Genese ist demnach denkbar. Da mehrere Organe durch die proliferierende Zellen betroffen sein können, sind die Beschwerden der Langerhanszell-Histiozytose vielgestaltig. Das am häufigsten betroffene Organ bei der erwachsenen Langerhanszell-Histiozytose ist die Lunge, gefolgt von den Knochen. In ⅓ der Fälle ist die Haut betroffen, sodass dem Dermatologen bei der Diagnosefindung eine ausgesprochen wichtige Rolle zukommt. Wegweisende Befunde sind die Trias erosive, ekzemartige Hautveränderungen am Kapillitium sowie in den Intertrigines in Kombination mit einem Diabetes insipidus. Die Diagnose wird letztlich histologisch gestellt. Typisch sind dichte Infiltrate, bestehend aus großen Zellen mit bohnenförmigem Zellkern, die immunhistochemisch durch Nachweis von CD1a-Antigen auf der Zelloberfläche charakterisiert sind.

Therapeutisch werden neben topischen Steroiden, PUVA, systemischen Immunsuppressiva auch teilweise Polychemotherapien sowie chirurgische und auch strahlentherapeutische Maßnahmen angewandt. Aufgrund der neuesten Erkenntnisse der bestehenden BRAF-Mutation wird derzeit auch der Einsatz von BRAF-Inhibitoren diskutiert.

Bei lokalisierten Formen der LCH ist die Prognose günstig. Der Ausgang der disseminierten Form ist abhängig vom Ausmaß des Organbefalls sowie vom Alter der Patienten. In seltenen Fällen wurden Entwicklungen zu akuten myeloischen Leukämien beobachtet. Aufgrund der Seltenheit der Erkrankungen hat sich bisher kein systematischer und interdisziplinärer Ansatz zur Diagnosestellung und Therapie ebenso wie kein langfristiges Nachsorgekonzept etabliert.

Optical coherence tomography for margin definition of basal cell carcinoma before micrographic surgery-recommendations regarding the marking and scanning technique

BACKGROUND/PURPOSE

Mohs Micrographic Surgery (MMS) is the preferred therapeutic treatment for high-risk basal cell carcinoma (BCC). Optical Coherence Tomography (OCT) is a non-invasive imaging technique that enables the diagnosis of BCC. We thought to determine the margins of BCCs with OCT, prior to MMS, to reduce the number of surgical steps.

METHODS

Different permanent markers were tested on the skin regarding line width, resistance against disinfection and brightness in the OCT image. The visible tumor margins of BCCs were defined by dermoscopy, adding a safety margin of 2 mm and labeled using the selected pen, causing a signal shadow in OCT. Scans of the center and of entire margin were performed. If parts of the BCC were visible outside the margin, another 2 mm were added and the scan was repeated until the tissue outside the labeling looked tumor free.

RESULTS

Eight out of ten BCCs were totally excised in a single stage when margin delineation was done by OCT. Macroscopic margins were enlarged after OCT scanning in four patients, saving further stages of MMS.

CONCLUSION

OCT may help to better define the microscopic dimensions of BCCs and therefore reduce the number of stages of MMS.

Fluorescence (Multiwave) Confocal Microscopy

In addition to reflectance confocal microscopy, multiwave confocal microscopes with different laser wavelengths in combination with exogenous fluorophores allow fluorescence mode confocal microscopy in vivo and ex vivo. Fluorescence mode confocal microscopy improves the contrast between the epithelium and the surrounding soft tissue and allows the depiction of certain structures, like epithelial tumors, nerves, and glands.

The sensitivity and specificity of optical coherence tomography for the assisted diagnosis of nonpigmented basal cell carcinoma: an observational study

BACKGROUND

The diagnostic criteria for basal cell carcinoma (BCC) using optical coherence tomography (OCT) have been described previously, but the clinical value of these findings remains unknown.

OBJECTIVES

To investigate the diagnostic value of OCT for BCC in a typical clinical setting. The primary efficacy end point was a diagnosis of BCC for each lesion. Secondary end points were the diagnosis of other possible conditions.

METHODS

This was an observational, prospective, multicentre study in which consecutive patients with nonpigmented pink lesions suspicious for BCC underwent clinical assessment, dermoscopy and OCT, with the diagnosis recorded at each stage. Once all diagnoses had been recorded, the histological results were disclosed. In total 164 patients with 256 lesions were recruited. Histology was missing for 21 lesions, leaving 235 lesions in 155 patients for analysis.

RESULTS

Sixty per cent of lesions (141 of 235) were identified as BCC by histology. A slight increase of sensitivity was noted following OCT, which did not reach statistical significance. The specificity increased significantly from 28·6% by clinical assessment to 54·3% using dermoscopy and to 75·3% with the addition of OCT (P < 0·001). The positive predictive value for the diagnosis of BCC using OCT was 85·2% [95% confidence interval (CI) 78·6-90·4], and the negative predictive value was 92·1% (95% CI 83·6-97·0). The accuracy of diagnosis for all lesions increased from 65·8% with clinical evaluation to 76·2% following additional dermoscopy and to 87·4% with the addition of OCT.

CONCLUSIONS

OCT significantly improved the diagnostic specificity for BCC compared with clinical assessment and dermoscopy alone.

Clinical performance of the Nevisense system in cutaneous melanoma detection: an international, multicentre, prospective and blinded clinical trial on efficacy and safety

BACKGROUND

Even though progress has been made, the detection of melanoma still poses a challenge. In light of this situation, the Nevisense electrical impedance spectroscopy (EIS) system (SciBase AB, Stockholm, Sweden) was designed and shown to have the potential to be used as an adjunct diagnostic tool for melanoma detection.

OBJECTIVES

To assess the effectiveness and safety of the Nevisense system in the distinction of benign lesions of the skin from melanoma with electrical impedance spectroscopy.

METHODS

This multicentre, prospective, and blinded clinical study was conducted at five American and 17 European investigational sites. All eligible skin lesions in the study were examined with the EIS-based Nevisense system, photographed, removed by excisional biopsy and subjected to histopathological evaluation. A postprocedure clinical follow-up was conducted at 7 ± 3 days from the initial measurement. A total of 1951 patients with 2416 lesions were enrolled into the study; 1943 lesions were eligible and evaluable for the primary efficacy end point, including 265 melanomas - 112 in situ and 153 invasive melanomas with a median Breslow thickness of 0·57 mm [48 basal cell carcinomas (BCCs) and seven squamous cell carcinomas (SCCs)].

RESULTS

The observed sensitivity of Nevisense was 96·6% (256 of 265 melanomas) with an exact one-sided 95% lower confidence bound estimated at 94·2% and an observed specificity of 34·4%, and an exact two-sided 95% confidence bound estimated at 32·0-36·9%. The positive and negative predictive values of Nevisense were 21·1% and 98·2%, respectively. The observed sensitivity for nonmelanoma skin cancer was 100% (55 of 48 BCCs and seven SCCs) with an exact two-sided 95% confidence bound estimated at 93·5-100·0%.

CONCLUSIONS

Nevisense is an accurate and safe device to support clinicians in the detection of cutaneous melanoma.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]

BACKGROUND

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).

METHODS

To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.

RESULTS

In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.

CONCLUSIONS

Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

Confocal laser scanning microscopy as a new valuable tool in the diagnosis of onychomycosis - comparison of six diagnostic methods

Onychomycosis is common and can mimic several different nail disorders. Accurate diagnosis is essential to choose the optimum antifungal therapy. The aim of this study was to evaluate the use of confocal laser scanning microscopy (CLSM) and optical coherence tomography (OCT) as new non-invasive diagnostic tools in onychomycosis and to compare them with the established techniques. In a prospective trial, 50 patients with suspected onychomycosis and 10 controls were examined by CLSM and OCT. Parallel KOH preparation, culture, PAS-staining and PCR were performed. PCR showed the highest sensitivity, followed by CLSM, PAS and KOH preparation. OCT offered the second best sensitivity but displayed the lowest specificity. CLSM and KOH preparation showed a high specificity and CLSM offered the best positive predictive value, similar to KOH preparation and OCT. Fungal culture showed the lowest sensitivity and the worst negative predictive value, yet culture and PCR are the only techniques able to identify genus and species. In summary, CLSM was comparable to PAS staining and superior to KOH preparation. Due to the low specificity we assess OCT not as appropriate. In the differentiation of species PCR outplays the fungal culture in terms of time and sensitivity.

Influence of expression of EGFR and PTEN on outcome in patients with primary glioblastoma treated with standard radiochemotherapy and cetuximab: Interim analysis from the GERT-Protocol

2050

Background: The epidermal growth factor receptor (EGFR) is commonly amplified, overexpressed, and mutated in glioblastoma (GBM). Anti-EGFR treatments have shown to be associated with EGFR deletion mutant variant III (EGFRvIII) expression in presence of PTEN expression, suggesting a prognostic role of EGFRvIII expression. We determined molecular biomarkers and correlated these with outcome in the GERT trial. Methods: To date, 39 patients were treated within the GERT protocol (Combs SE et al., 2006) evaluating radiochemotherapy (RCHT) with temozolomide (TMZ) and weekly CTX. Pretreatment paraffin-embedded tumor tissue of 32 patients was available for molecular analysis. Twenty-three patients were male, 9 were female. Median age was 49 years. We analyzed amplification of EGFR, expression of EGFR, EGFRvIII, the tumor-suppressor PTEN and O(6)-methylguanine DNA methyltransferase (MGMT) gene promoter methylation. Results: Median follow-up was 12 months. Overall survival (OS) at 12 and 24 months was 89% and 42%. Progression-free survival (PFS) was 76% and 45% at 6 and 12 months, respectively. MGMT promoter hypermethylation was detected in 16/32 tumours. Methylated MGMT did not impact PFS or OS (p = 0.48 and p = 0.08). Data on EGFR copy number of 31/32 tumors showed EGFR gene amplification in 11 tumors. EGFR protein expression was found in 23/32 patients. EGFR-amplification did not impact PFS or OS (p = 0.56, p = 0.3). Patients with EGFR expression showed longer PFS (p = 0.05), but unaltered OS (p = 0.06). EGFRvIII was seen in 5/32 patients, only in tumors with EGFR amplification. Expression of EGFRvIII did not influence PFS (p = 0.26) or OS (p = 0.09). Reduced PTEN (22/32) did not influence PFS or OS (p = 0.27, p = 0.85). Outcome was not associated with coexpression of EGFRvIII and PTEN (n = 5); coexpression of EGFR and PTEN (n = 13) significantly influenced PFS (p = 0.005), but not OS (p = 0.10). Conclusions: Expression of EGFR, and coexpression of EGFR/PTEN is associated with significant increase in PFS after RCHT with TMZ and CTX. EGFR-amplification, reduction of PTEN expression and expression of EGFRvIII did not impact PFS nor OS. Randomized data in the primary treatment of GBM might help identify patients for anti-EGFR therapies.

[Table: see text]

Evaluation of the atrophogenic potential of different glucocorticoids using optical coherence tomography, 20-MHz ultrasound and profilometry; a double-blind, placebo-controlled trial

BACKGROUND

Skin atrophy is one of the main side-effects of topical corticosteroid therapy. Although the use of high-frequency ultrasound is an established method that has been studied previously, it allows measurements of the slow-reacting dermal thickness only.

OBJECTIVES

To investigate the decreasing epidermal thickness, which occurs earlier, we used optical coherence tomography (OCT), a high-resolution noninvasive imaging technique, and compared it with 20-MHz ultrasound and profilometry.

PATIENTS/METHODS

In this double-blind placebo-controlled trial 20 healthy volunteers applied four different corticosteroids and the cream base formulation as placebo to the volar part of both arms once a day over a 4-week period. The epidermal thickness, the dermal thickness and the skin surface roughness were assessed using OCT, high-frequency ultrasound and profilometry.

RESULTS

Each of the three methods allowed the detection and monitoring of significant corticosteroid-induced skin atrophy and its reversibility. The changes correlated with the potency of the steroids. The epidermal thickness decreased significantly in all test areas, even in the placebo and the untreated fields. As expected, the reduction in epidermal thickness was more pronounced and could be detected earlier by OCT than the reduction of dermal thickness using ultrasound. The epidermal surface roughness investigated using profilometry showed a slight smoothing.

CONCLUSIONS

OCT allows a simple, fast and noninvasive in vivo measurement of the epidermal thickness. To evaluate the atrophogenic potential of corticosteroids it is more suitable than high-frequency ultrasound as epidermal thickness decreases earlier. In addition, epidermal thickness is a more sensitive indicator of steroid atrophy as the degree of thinning is much higher compared with the dermal atrophy. Profilometry might give further information; however, it would not be suitable for clinical use as the results were generally less pronounced. In the future, OCT might be useful to detect corticosteroid-induced side-effects at the beginning for monitoring the therapy.