Reflectance confocal microscopy features of mycosis fungoides and Sézary syndrome: correlation with histopathologic and T-cell receptor rearrangement studies

Non-invasive Skin Imaging in Cutaneous Lymphomas

The diagnosis of cutaneous lymphomas is challenging and requires skin tissue for histology and immunophenotyping using immunohistochemistry and molecular studies. In recent years, the role of non-invasive imaging techniques has been described as part of the clinical assessment of cutaneous lymphoma lesions. Imaging modalities such as dermoscopy, reflectance confocal microscopy (RCM), and high frequency ultrasound (HFUS) have been shown to be very valuable in raising the clinical suspicion for lymphomas of the skin, and in distinguishing cutaneous lymphomas from inflammatory dermatoses such as lupus, psoriasis, or eczema. These non-invasive methods can be used to direct the clinician to the optimal biopsy site to maximize the histopathological results and minimize false negatives. These methods also have a potential place in monitoring treatment response. In this review we present a concise summary of the dermoscopic imaging, RCM, and HFUS features seen in cutaneous T-cell lymphomas (CTCL) and B-cell lymphomas (CBCL).

Cutaneous lymphomas in African American/Black patients: pitfalls and presentations

This review describes and highlights differences in clinical presentations of cutaneous lymphomas (CLs), particularly in darker skin types, i.e., Skin of Color (SOC). We illustrate differences in clinical features on physical exam that can be a diagnostic challenge and suggest ways to recognize and identify these conditions at an early stage through a high level of suspicion. The review includes a summary of the epidemiology of various CLs, specifically highlighting the presentation and incidence in African American/Black patients, where the data are available. We also include a discussion of adult HTLV-1-associated T-cell leukemia/lymphoma (ATLL) which, although a systemic T-cell lymphoma, may present with skin manifestations and mimic MF, other CTCL subtypes, or other inflammatory dermatoses. Finally, this review highlights the possible use of imaging modalities, such as dermoscopy and reflectance-confocal microscopy, in diagnosing and recognizing cutaneous lymphomas in patients with darker skin types.

Topical Bimiralisib Shows Meaningful Cutaneous Drug Levels in Healthy Volunteers and Mycosis Fungoides Patients but No Clinical Activity in a First-in-Human, Randomized Controlled Trial

Mycosis fungoides (MF) is a subtype of CTCL with a low incidence and high medical need for novel treatments. The objective of this randomized, placebo-controlled, double-blinded, first-in-human study was to evaluate safety, efficacy, cutaneous and systemic pharmacokinetics (PK) of topical bimiralisib in healthy volunteers (HVs) and MF patients. In this trial, a total of 6 HVs and 19 early-stage MF patients were treated with 2.0% bimiralisib gel and/or placebo. Drug efficacy was assessed by the Composite Assessment of Index Lesion Severity (CAILS) score, supported by objective measuring methods to quantify lesion severity. PK blood samples were collected frequently and cutaneous PK was investigated in skin punch biopsies on the last day of treatment. Local distribution of bimiralisib in HVs showed a mean exposure of 2.54 µg/g in the epidermis. A systemic concentration was observed after application of a target dose of 2 mg/cm² on 400 cm², with a mean C_avg of 0.96 ng/mL. Systemic exposure of bimiralisib was reached in all treated MF patients, and normalized plasma concentrations showed a 144% increased exposure compared to HVs, with an observed mean C_avg of 4.49 ng/mL and a mean cutaneous concentration of 5.3 µg/g. No difference in CAILS or objective lesion severity quantification upon 42 days of once-daily treatment was observed in the MF patient group. In general, the treatment was well tolerated in terms of local reactions as well as systemic adverse events. In conclusion, we showed that topical bimiralisib treatment leads to (i) meaningful cutaneous drug levels and (ii) well-tolerated systemic drug exposure in MF patients and (iii) a lack of clinical efficacy, in need of further exploration due to numerous unknown factors, before depreciation of topical bimiralisib as a novel therapeutic drug for CTCLs.

Correlation Between In Vivo Reflectance Confocal Microscopy and Horizontal Histopathology in Skin Cancer: A Review

In dermatopathological daily practice, vertical histopathology sections are classically used to analyze skin biopsies. Conversely, horizontal histopathological sections are currently used for the diagnosis of some types of alopecia. In the last years the morphological findings obtained by horizontal histopathology have been correlated to those obtained by in vivo reflectance confocal microscopy which provides the same “point of view” of the skin. This review paper emphasizes the strong matching and correlation between reflectance confocal microscopy images and horizontal histopathology in cutaneous neoplasms, further demonstrating the strong reliability of this innovative, non-invasive technique in the management of skin tumors.

Reflectance Confocal Microscopy, Optical Coherence Tomography, and Multiphoton Microscopy in Inflammatory Skin Disease Diagnosis

BACKGROUND AND OBJECTIVES

Technological advances in medicine have brought about many novel skin imaging devices. This review aims to evaluate the scientific evidence supporting the use of noninvasive optical imaging techniques to aid in the diagnosis and prognosis of inflammatory skin diseases.

STUDY DESIGN/MATERIALS AND METHODS

PubMed and Scopus were searched in September 2020 according to PRISMA guidelines for articles using reflectance confocal microscopy (RCM), optical coherence tomography (OCT), and multiphoton microscopy (MPM) in inflammatory skin diseases, excluding studies monitoring treatment efficacy.

RESULTS

At the time of the study, there were 66 articles that addressed the utilization of noninvasive imaging in interface, spongiotic, psoriasiform, vesiculobullous, and fibrosing/sclerosing inflammatory skin dermatoses: RCM was utilized in 46, OCT in 16, and MPM in 5 articles. RCM was most investigated in psoriasiform dermatoses, whereas OCT and MPM were both most investigated in spongiotic dermatoses, including atopic dermatitis and allergic contact dermatitis.

CONCLUSIONS

There is preliminary evidence to support the diagnostic potential of noninvasive optical imaging techniques in inflammatory skin diseases. Improvements in the devices and further correlation with histology will help broaden their utility. Additional studies are needed to determine the parameters for diagnostic features, disease differentiation, and staging of inflammatory skin conditions. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

The Differential Diagnosis of Hypopigmented Mycosis Fungoides and Vitiligo With Reflectance Confocal Microscopy: A Preliminary Study

Objective: To investigate the role of reflectance confocal microscopy (RCM) in the differential diagnosis of hypopigmented mycosis fungoides (HMF) and vitiligo.

Methods: Cases with persistent hypopigmented patches, suspicious of early stage vitiligo, or HMF were imaged with RCM. The melanin contents and inflammatory conditions of the epidermis and superficial dermis of the lesions were compared with the same layers of the adjacent skin, and then, the imaged lesions were biopsied and analyzed by histology.

Results: 15 cases were enrolled in this study, and based on the RCM findings, there was just slight or moderate reduction of melanin but no melanin absence in the basal cell layer of HMF lesions. The finding of monomorphous weakly refractile, oval to round cells on the basis of vesicle-like dark space was clearly elucidated in the epidermis of the lesions by RCM, which indicates the Pautrier's microabscesses on histopathology. Among those 15 cases, 13 cases were identified as HMF, and the other two cases were vitiligo, based on RCM findings, which were confirmed by histology analysis.

Conclusions: The RCM findings correlated well with histology results in the screening of HMF, which indicates the RCM is an important tool in the early detection and differential diagnosis of HMF.

Reflectance confocal microscopy role in mycosis fungoides follow-up

BACKGROUND

Reflectance confocal microscopy (RCM) is a useful tool for many skin cancers, allowing non-invasive evaluation over time and identifying areas of active disease. Its role to follow-up mycosis fungoides (MF) patients has not yet been evaluated.

OBJECTIVE

To assess the level of agreement between RCM and histopathology and to develop a RCM checklist that could help monitoring MF patients.

METHOD

Prospective study in a cutaneous lymphoma clinic of a tertiary hospital in Australia. RCM and biopsies were performed on the same area at baseline, before commencing or changing treatment, and at 6 months after starting treatment. Normal skin sites were also analysed and acted as controls. RCM features and histopathological findings were blindly evaluated by the confocalist and pathologist. Correlation between RCM and histology was measured by overall per cent of agreement (OPA), kappa and ROC curves. Additionally, RCM images before and after treatment were assessed blinded from clinical information and correlated to clinical assessment.

RESULTS

Thirty-eight MF lesions were included. Nineteen of these 38 were re-assessed by RCM 6 months later. Fifty biopsies were performed (38 at baseline and 12 after 6 months). The combination of four RCM features corresponding to Pautrier's microabscess, epidermal and junctional lymphocytes and interface dermatitis formed the RCM checklist for MF that predicted the severity of disease with AUC of 0.95 (P = .003).

CONCLUSION

Reflectance confocal microscopy can assess activity within a lesion and over time and assist in the clinical management of patients with MF.

Reflectance confocal microscopy may be included as part of the diagnostic algorithm of early-stage mycosis fungoides

INTRODUCTION

Reflectance confocal microscopy (RCM), a noninvasive, real-time technique of computed tomography, has been widely used for pigmentary, inflammatory, and tumor diseases of the skin.

AIM

Our main purpose was to analyze the consistency between pathological and RCM characteristics of early-stage mycosis fungoides (MF) and the utility of RCM in the diagnosis of early-stage MF.

METHODS

According to the RCM features of MF in the early stage, the biopsy sites of 40 cases of suspected MF and 20 cases of chronic inflammatory skin diseases clinically were preliminarily located. Histopathologic and immunohistochemical examinations were performed to make a diagnosis based on the diagnostic algorithm proposed by the International Society for Cutaneous Lymphomas.

RESULTS

Among the 60 patients observed, there were 12 confirming cases of MF, 14 suspecting cases, 6 not completely excluding cases, and 28 eliminating cases according to the diagnostic algorithm, as well as characteristics of RCM were typical in 8 cases, suspected in 16 cases, not excluded in 3 cases, and excluded in 33 cases. The kappa value was 0.769 (P < .01), which means there is a strong consistency between the classification by RCM and the diagnosis algorithm. MF in patch stage and plaque stage (IA to IIB) has typical characteristics of RCM, respectively.

CONCLUSIONS

RCM can be used as an objective and convenient auxiliary means to diagnose early-stage MF and may be included as part of the diagnostic algorithm of early-stage MF.

A Scoping Review of Non-invasive Imaging Modalities in Dermatological Disease: Potential Novel Biomarkers in Hidradenitis Suppurativa

Background: The development of imaging-based biomarkers has the potential to overcome major challenges in the accurate and reproducible assessment of disease severity and response to novel therapies in Hidradenitis Suppurativa (HS). Understanding the advantages and limitations of existing non-invasive imaging modalities in dermatological disease will aid in the development of hypotheses and inform the design of future studies. Methods: A scoping review was performed using Medline, Embase, Web of Science Databases and evaluation of "gray literature" until June 30, 2019. Citations were examined according to pre-defined inclusion and exclusion criteria. Citations were reviewed by two independent reviewers. Narrative Synthesis was used to summarize data, structured by imaging modality. Results: Non-invasive imaging modalities, such as ultrasound, MRI, RCM, EIS, OCT, and MIT, were identified. Only ultrasound, MRI and MIT have been used in HS. Image modalities vary in image depth, resolution, cost, accessibility and correlation with known aspects of disease activity in HS. Discussion and Conclusion: The benefits and limitations of each imaging modality are products of cost, accessibility, validity and reliability. An additional hurdle to the development of image-based biomarkers in HS is a lack of established analytical benchmarks that can be correlated with existing biological, inflammatory and clinical parameters. This review has identified potential imaging biomarkers, as well as relevant analytical benchmarks that reflect the presence or absence of disease. Further investigation work is needed to analytically and clinically validate these imaging variables in order to identify potential imaging biomarkers in HS.

Systematic review and proposal of an in vivo reflectance confocal microscopy assessment tool for cutaneous lymphoma

BACKGROUND

Reflectance confocal microscopy (RCM) is a non-invasive imaging technique that provides dynamic information and allows in vivo monitoring, with excellent histologic correlation. In the last decade, the use of RCM for cutaneous T-cell lymphomas (CTCL) has been reported. CTCL may require multiple biopsies for diagnosis due to its equivocal clinical presentation. RCM was described as a possible tool to help determine the best site for skin biopsy. This study aims to systematically review all RCM features reported in literature for CTCL.

METHOD

A systematic literature search concerning CTCL evaluated by RCM was performed in eight electronic databases until May 2019 following PRISMA-DTA quality assessment.

RESULTS

Eighteen RCM features were described in patients with CTCL. The most frequent were: interface dermatitis (89%), epidermal lymphocytes (82%), epidermal architectural disarray (81%), and vesicle-like structure (Pautrier microabscess) (51%).

CONCLUSION

In order to establish comparable parameters among the studies identified, we proposed descriptors for CTCL features and a grading system to quantify them. This will facilitate to define the role of RCM in the diagnosis and monitoring of CTCL patients.

Current and future applications of confocal laser scanning microscopy imaging in skin oncology

Confocal laser scanning microscopy (CLSM) is a modern imaging technique that enables the in vivo or ex vivo characterization of skin lesions located in the epidermis and superficial dermis with a high quasi-microscopic resolution. Currently, it is considered to be the most promising imaging tool for the evaluation of superficial skin tumors. The in vivo mode adds the advantage of noninvasive, dynamic, in real-time assessment of the tumor associated vasculature and inflammation. It offers the possibility to repeatedly examine the same skin area without causing any damage and to monitor disease progression and treatment outcome. Furthermore, this novel technology allows the evaluation of the entire lesion and can be used to guide biopsies and to define tumor margins before surgical excision or other invasive therapies. CLSM diagnostic features may differentiate between the various histologic subtypes of skin tumors and therefore helps in choosing the best therapeutic approach. In this study, we present the CLSM characteristic features of the most common melanocytic and non-melanocytic skin tumors, as well as future possible CLSM applications in the study of experimental skin tumorigenesis on animal models.

Cutaneous T-cell Lymphoma

Cutaneous T-cell lymphomas comprise a heterogeneous group of diseases characterized by monoclonal proliferations of T lymphocytes primarily involving skin, modified skin appendages, and some mucosal sites. This article addresses the basic clinical, histologic, and immunohistochemical characteristics of this group of diseases, with additional attention to evolving literature on dermoscopy, reflectance confocal microscopy, flow cytometry, and molecular data that may increasingly be applied to diagnostic and therapeutic algorithms in these diseases. Select unusual phenotypes or diagnostic examples of classic phenotypes are demonstrated, and flags for consideration while making a pathologic diagnosis of cutaneous T-cell lymphoma are suggested.

The Role of Oncodermatology in the Care of Patients Receiving Cancer Therapy

OBJECTIVE

To review the emerging sub-specialty of oncodermatology and the role of oncodermatology nurses as facilitators of interprofessional collaboration between the oncology team and the dermatology team.

DATA SOURCES

Journal articles indexed on the National Library of Medicine database.

CONCLUSION

The complexity of cancer care with new cancer therapies and their associated dermatologic adverse events profiles benefit from a collaborative, interprofessional approach between dermatology and oncology in the care of the patient with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Oncodermatology nurses are in roles that can facilitate interprofessional collaboration, optimizing the care of patients with cancer.