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O'Hern K, Crum OM, Demer AM, Brewer JD. Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis. Dermatol Surg 2024; 50:601-610. [PMID: 38530980 DOI: 10.1097/dss.0000000000004164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) is increasingly used to treat cutaneous melanoma. However, it is unclear whether intraoperative immunohistochemistry (IHC) improves surgical outcomes. OBJECTIVE To determine whether intraoperative IHC during MMS and staged excision is associated with a decreased risk of poor surgical outcomes. MATERIALS AND METHODS Search of 6 databases identified comparative and noncomparative studies that reported local recurrence after MMS or staged excision with or without IHC for melanoma. Random-effects meta-analysis was used to estimate pooled local recurrence rates, nodal recurrence, distant recurrence, and disease-specific mortality. RESULTS Overall, 57 studies representing 12,043 patients with cutaneous melanoma and 12,590 tumors met inclusion criteria. Combined MMS and staged excision with IHC was associated with decreased local recurrence in patients with invasive melanoma (0.3%, 95% CI: 0-0.6) versus hematoxylin and eosin alone (1.8%, 95% CI: 0.8%-2.8%) [ p < .001]. Secondary outcomes including nodal recurrence, distant recurrence, and disease-specific mortality were not significantly different between these 2 groups. Study heterogeneity was moderately-high. CONCLUSION Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC. These findings suggest that the use of intraoperative IHC during MMS or staged excision should strongly be considered, particularly for invasive melanoma.Trial Registration PROSPERO Identifier: CRD42023435630.
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Affiliation(s)
- Keegan O'Hern
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Olivia M Crum
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Addison M Demer
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jerry D Brewer
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
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2
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Mansilla-Polo M, Morgado-Carrasco D, Toll A. Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:555-571. [PMID: 38395222 DOI: 10.1016/j.ad.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/29/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.
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Affiliation(s)
- M Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Health Research Institute (IIS) La Fe, Valencia, Spain
| | - D Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Department of Dermatology, Hospital de Figueres, Fundació Alt Empordà, Spain
| | - A Toll
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.
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3
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Mansilla-Polo M, Morgado-Carrasco D, Toll A. Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T555-T571. [PMID: 38648936 DOI: 10.1016/j.ad.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/29/2023] [Accepted: 02/06/2024] [Indexed: 04/25/2024] Open
Abstract
Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.
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Affiliation(s)
- M Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, España; Health Research Institute (IIS) La Fe, Valencia, España
| | - D Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España; Department of Dermatology, Hospital de Figueres, Fundació Alt Empordà, España
| | - A Toll
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España.
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4
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Martinez-Molina M, Richarz N, Jaka A, Bassas-Vila J, Mora-Fernández V, Pi-Sunyer AQ, Podlipnik S, Carrascosa JM, Boada A. Spaghetti Technique Versus Wide Local Excision for Lentigo Maligna Affecting the Head and Neck Regions: Surgical Outcome and Descriptive Analysis of 79 Cases from a Single Practice Cohort. Dermatol Pract Concept 2023; 13:e2023193. [PMID: 37557139 PMCID: PMC10412079 DOI: 10.5826/dpc.1303a193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Lentigo maligna is a subtype of melanoma in situ that typically affects the head and neck region with an increasing incidence. Margin-controlled techniques, such as spaghetti technique (ST), have gained popularity over wide local excision (WLE) with a margin of 5 mm. OBJECTIVES To evaluate the outcomes of lentigo maligna cases in the head and neck area treated by either WLE or ST in a tertiary referral hospital. The secondary goal was to describe the demographic and clinical characteristics of our series. METHODS Cohort study of patients diagnosed with lentigo maligna on the head and neck region between January 2014 and February 2022 in a tertiary hospital. RESULTS In total, 79 lentigo maligna were studied, corresponding to 77 patients. Fifty-three lesions (67%) were treated with WLE and 26 (33%) with ST. The mean age of the patients was 73 years and 58% were men. Most of the tumors were located on the cheek (50%) and mean lesion diameter was 2.2 cm for the ST group and 1.2 cm for the WLE group. Mean duration follow-up was 44 months. There were two local recurrences in the WLE group (2/53; 3.7%) and none in the ST group. CONCLUSIONS Both WLE and ST are appropriate surgical approaches for lentigo maligna. ST offers an efficient alternative to Mohs surgery for treating lentigo maligna in the head and neck area, especially when guided by reflectance confocal microscopy.
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Affiliation(s)
- Manel Martinez-Molina
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Nina Richarz
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Ane Jaka
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Juli Bassas-Vila
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Verónica Mora-Fernández
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Ariadna Quer Pi-Sunyer
- Department of Pathology, Hospital University Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Sebastian Podlipnik
- Department of Dermatology, Melanoma Unit, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Manuel Carrascosa
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Aram Boada
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
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5
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Navarrete-Dechent C, Cordova M, Aleissa S, Liopyris K, Dusza SW, Kose K, Busam KJ, Hollman T, Lezcano C, Pulitzer M, Chen CSJ, Lee EH, Rossi AM, Nehal KS. Lentigo maligna melanoma mapping using reflectance confocal microscopy correlates with staged excision: A prospective study. J Am Acad Dermatol 2023; 88:371-379. [PMID: 31812621 PMCID: PMC10210015 DOI: 10.1016/j.jaad.2019.11.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/03/2019] [Accepted: 11/25/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lentigo maligna/lentigo maligna melanoma (LM/LMM) can present with subclinical extension that may be difficult to define preoperatively and lead to incomplete excision and potential recurrence. Preliminarily studies have used reflectance confocal microscopy (RCM) to assess LM/LMM margins. OBJECTIVE To evaluate the correlation of LM/LMM subclinical extension defined by RCM compared with the gold standard histopathology. METHODS Prospective study of LM/LMM patients referred for dermatologic surgery. RCM was performed at the clinically defined initial surgical margin followed by margin-controlled staged excision with paraffin-embedded tissue, and histopathology was correlated with RCM results. RESULTS Seventy-two patients were included. Mean age was 66.8 years (standard deviation, 11.1; range, 38-89); 69.4% were men. Seventy of 72 lesions (97.2%) were located on the head and neck with mean largest clinical diameter of 1.3 cm (range, 0.3-5). Diagnostic accuracy for detection of residual melanoma in the tumor debulk (after biopsy) had a sensitivity of 96.7% and a specificity of 66.7% when compared with histopathology. RCM margin assessment revealed an overall agreement with final histopathology of 85.9% (κ = 0.71; P < .001). LIMITATIONS No RCM imaging beyond initial planned margins was performed. CONCLUSION RCM showed moderate to excellent overall agreement between RCM imaging of LM/LMM and histopathology of staged excision margins.
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Affiliation(s)
- Cristian Navarrete-Dechent
- Department of Dermatology, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel Cordova
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Saud Aleissa
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Konstantinos Liopyris
- Department of Dermatology, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Stephen W Dusza
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kivanc Kose
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Klaus J Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Travis Hollman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cecilia Lezcano
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Pulitzer
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chih-Shan J Chen
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erica H Lee
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony M Rossi
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kishwer S Nehal
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York.
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6
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Pizzichetta MA, Polesel J, Perrot JL, Rubegni P, Fiorani D, Rizzo A, Stanganelli I, Magi S, Mazzoni L, Medri M, Dominici MM, Toffolutti F, Farnetani F, Lippolis N, Pedroni G, Ciardo S, Condorelli AG, Conforti C, Pellacani G, Zalaudek I, Puglisi F, Cinotti E. Amelanotic/hypomelanotic lentigo maligna: Dermoscopic and confocal features predicting diagnosis. J Eur Acad Dermatol Venereol 2023; 37:303-310. [PMID: 36196781 PMCID: PMC10092015 DOI: 10.1111/jdv.18636] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/12/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Amelanotic/hypomelanotic lentigo maligna and lentigo maligna melanoma (AHLM/LMM) may be very difficult to diagnose at an early stage. OBJECTIVES To quantify the predictive value of dermoscopic and reflectance confocal microscopy (RCM) features for AHLM/LMM. METHODS Dermoscopic and RCM images of histopathologically diagnosed AHLM/LMM, amelanotic/hypomelanotic benign lesions (AHBL), and amelanotic/hypomelanotic basal and squamous cell carcinomas (AHBCC/AHSCC) of the head and neck from consecutive patients were retrospectively collected and blindly evaluated by three observers to assess presence or absence of dermoscopic and RCM criteria. RESULTS Overall, 224 lesions in 216 patients including LM/LMM (n = 55, 24.6%), AHBL (n = 107, 47.8%) and AHBCC/AHSCC (n = 62, 27.7%) were analysed. Multivariable analysis showed that milky-red areas (OR = 5.46; 95% CI: 1.51-19.75), peripheral light brown structureless areas (OR = 19.10; 4.45-81.96), linear irregular vessels (OR = 5.44; 1.45-20.40), and asymmetric pigmented follicles (OR = 14.45; 2.77-75.44) at dermoscopy, and ≥3 atypical cells in five fields (OR = 10.12; 3.00-34.12) and focal follicular localization of atypical cells at dermo-epidermal junction (DEJ) (OR = 10.48; 1.10-99.81) at RCM were significantly independent diagnostic factors for AHLM/LMM vs. AHBL. In comparison with AHBCC/AHSCC, peripheral light brown structureless area (OR = 7.11; 1.53-32.96), pseudonetwork around hair follicles (OR = 16.69; 2.73-102.07), and annular granular structures (OR = 42.36; 3.51-511.16) at dermoscopy and large dendritic (OR = 6.86; 3.15-38.28) and round pagetoid cells (OR = 26.78; 3.15-227.98) at RCM led to a significantly increased risk of diagnosing AHLM/LMM. CONCLUSIONS Amelanotic/hypomelanotic lentigo maligna and lentigo maligna melanoma may have the same dermoscopic features of AHM on other body sites, such as milky red areas, peripheral light brown structureless areas and linear irregular vessels. These features, asymmetric pigmented follicles and at RCM ≥ 3 atypical cells in five fields and focal follicular extension of atypical cells at DEJ may help in recognizing AHLM/LMM even when LM conventional features (e.g., obliteration of hair follicles under dermoscopy and large pagetoid cells under RCM) are absent or present only in very small areas of the lesion.
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Affiliation(s)
- Maria A Pizzichetta
- Department of Dermatology, University of Trieste, Trieste, Italy.,Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Jerry Polesel
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Jean L Perrot
- Department of Dermatology, University Hospital of Saint Etienne, Saint-Etienne, France
| | - Pietro Rubegni
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Diletta Fiorani
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Arianna Rizzo
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Ignazio Stanganelli
- Department of Dermatology, University of Parma, Parma, Italy.,Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Serena Magi
- Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Laura Mazzoni
- Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Matelda Medri
- Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Michele M Dominici
- Division of Dermatology, Department of Medicina and Surgery, Azienda Ospedaliera-Universitaria di Parma, Parma, Italy
| | - Federica Toffolutti
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Francesca Farnetani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Lippolis
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Gioia Pedroni
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvana Ciardo
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra G Condorelli
- Dermatologic Unit, Department of Medical Specialities Arcispedale Santa Maria Nuova, IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Claudio Conforti
- Department of Dermatology, University of Trieste, Trieste, Italy
| | - Giovanni Pellacani
- Department of Dermatology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Iris Zalaudek
- Department of Dermatology, University of Trieste, Trieste, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.,Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Elisa Cinotti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
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7
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Elshot YS, Tio DCKS, van Haersma-de With ASE, Ouwerkerk W, Zupan-Kajcovski B, Crijns MB, Limpens CEJM, Klop WMC, Bekkenk MW, Balm AJM, de Rie MA. Lentigo maligna (melanoma): A systematic review and meta-analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy. J Eur Acad Dermatol Venereol 2023; 37:871-883. [PMID: 36652277 DOI: 10.1111/jdv.18880] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non-Randomized Studies instrument. Meta-analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline-recommended margin was insufficient in 21.6%-44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%-1.9%), and highest for WLE (13%; 95% CI, 7.2%-21.6%). The mean follow-up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld-RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma-associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH-RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.
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Affiliation(s)
- Y S Elshot
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - D C K S Tio
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - W Ouwerkerk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Infection & Immunity Institute, Cancer Center, University of Amsterdam, Amsterdam, The Netherlands.,National Heart Centre Singapore, Singapore, Singapore
| | - B Zupan-Kajcovski
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M B Crijns
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - C E J M Limpens
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W M C Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Bekkenk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A J M Balm
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A de Rie
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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8
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Elshot YS, Zupan-Kajcovski B, Ouwerkerk W, Klop WMC, Lohuis PJFM, Bol M, Crijns MB, Bekkenk MW, de Rie MA, Balm AJM. A cohort analysis of surgically treated primary head and neck lentigo maligna (melanoma): Prognostic value of melanoma subtype and new insights in the clinical value of guideline adherence. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:818-824. [PMID: 36031471 DOI: 10.1016/j.ejso.2022.08.012] [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: 04/04/2022] [Revised: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Knowledge about lentigo maligna (melanoma) (LM/LMM) and its associated prognostic clinicopathological characteristics are limited compared to that of non-LM/LMM subtypes. The current study aimed to determine the clinical relevance of the LM/LMM subtype and its influence on recurrence and survival outcomes. METHODS All consecutive cases of primary cutaneous head and neck LM/LMM treated by wide local excision over a ten-year period were retrospectively reviewed and compared to non-LM/LMM. Clinical outcome and prognostic factors were assessed by cumulative incidence and competing risk analyses. RESULTS A total of 345 patients were identified. Specific clinicopathological characteristics such as lower median Breslow thickness (1.6 mm versus 2.1 mm; P = 0.013), association with diagnostic sampling errors (17.3% versus 5.2%; P = 0.01), and increased risk of local recurrences due to incomplete resection (18.7% versus 2.3%; P < 0.001), were significantly associated with LM/LMM. Guideline adherence was similar between the two study groups. The positive nodal status at baseline for LMM was low compared to non-LM/LMM (4.2% vs 17.9%; P = 0.037). The LMM subtype, facial localization, and reduced surgical margins (i.e., guideline non-adherence) were not shown to be independent prognostic factors for disease-free, melanoma-specific, or overall survival after correction for competing risks such as patient age and Breslow thickness. CONCLUSIONS The LMM subtype was not shown to be prognostically different from non-LM/LMM when corrected for other variables of influence such as patient age and Breslow thickness. Reduced resection margins did not seem to affect disease-free, and melanoma-specific survival and warrant LM/LMM-specific guidelines. Further research is needed to evaluate the value of SLNB in LMM patients.
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Affiliation(s)
- Yannick S Elshot
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands; Department of Dermatology, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands.
| | - Biljana Zupan-Kajcovski
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands
| | - Wouter Ouwerkerk
- Department of Dermatology, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands; Amsterdam Infection & Immunity Institute, Cancer Center, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands
| | - W Martin C Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands
| | - Peter J F M Lohuis
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands
| | - Mijke Bol
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands
| | - Marianne B Crijns
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands
| | - Marcel W Bekkenk
- Department of Dermatology, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands
| | - Menno A de Rie
- Department of Dermatology, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands
| | - Alfons J M Balm
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Postbus 90203, 1006 BE, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Univ. of Amsterdam, Postbus 22660, 1100 DD, Amsterdam, the Netherlands
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9
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Di Matteo E, Pampena R, Pizzichetta MA, Cinotti E, Chester J, Kaleci S, Manfredini M, Guida S, Dika E, Moscarella E, Lallas A, Apalla Z, Argenziano G, Perrot JL, Tognetti L, Lai M, Cantisani C, Roberti V, Fiorani D, Baraldi C, Veneziano L, Papageorgiou C, Ciardo S, Rubegni P, Zalaudek I, Patrizi A, Longo C, Bianchi L, Pellacani G, Farnetani F. Unusual Dermoscopic Patterns of Basal Cell Carcinoma Mimicking Melanoma. Exp Dermatol 2022; 31:890-898. [PMID: 35102605 PMCID: PMC9305787 DOI: 10.1111/exd.14533] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/23/2021] [Accepted: 01/27/2022] [Indexed: 12/25/2022]
Abstract
Background Basal cell carcinoma can simulate melanoma and specific dermoscopic criteria have not yet been defined in a large cohort. Objective To identify dermoscopic “trump” characteristics for differential diagnosis, identify cluster groups and assess the clinical impact of this study's findings. Methods Retrospective, multicentric comparative study of atypical, non‐facial basal cell carcinoma (≥1 seven‐point checklist criteria) and melanoma (with at least one BCC criteria) at dermoscopy. Observed dermoscopic features were used to develop a proposed score. Lesion clusters were defined with hierarchical analysis. Clinical impact was assessed with a blinded reader study following this study's results. Results A total of 146 basal cell carcinoma and 76 melanoma were included. Atypical vascular pattern was common to most lesions (74.5%). Twelve trump features were included in the proposed score (sensitivity 94.1% and specificity 79.5%). Cluster analysis identified 3 basal cell carcinoma and 3 melanoma clusters. Findings improved overall diagnostic accuracy and confidence (26.8% and 13.8%, respectively; p < 0.001). Conclusions These findings support the notion that atypical vascular pattern should be considered a shared feature of both melanoma and atypical basal cell carcinoma. Our proposed score improves diagnostic accuracy and confidence. Absence of pigmented features was associated with lower diagnostic accuracy and confidence.
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Affiliation(s)
- Eleonora Di Matteo
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133, Rome, Italy.,Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Maria A Pizzichetta
- Division Medical Oncology and Preventive Oncology, National Cancer Institute, Aviano, Italy.,Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Elisa Cinotti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria Alle Scotte Hospital, Viale Bracci 16, Siena, 53100, Italy
| | - Johanna Chester
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Shaniko Kaleci
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Manfredini
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefania Guida
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Emi Dika
- Dermatology, IRCCS di Policlinico Sant'Orsola Hospital, Bologna, Italy.,Dermatology Section, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, 40138, Bologna, Italy
| | - Elvira Moscarella
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Aimilios Lallas
- First Department of Dermatology, School of Medicine, Aristotle University, Thessaloniki, Greece
| | - Zoe Apalla
- Second Department of Dermatology, School of Medicine, Aristotle University, Thessaloniki, Greece
| | | | - Jian L Perrot
- Department of Dermatology, University Hospital of Saint-Etienne, Saint-Etienne Cedex 2 42055, France
| | - Linda Tognetti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria Alle Scotte Hospital, Viale Bracci 16, Siena, 53100, Italy
| | - Michela Lai
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy.,Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Carmen Cantisani
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Roberti
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Diletta Fiorani
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria Alle Scotte Hospital, Viale Bracci 16, Siena, 53100, Italy
| | - Carlotta Baraldi
- Dermatology, IRCCS di Policlinico Sant'Orsola Hospital, Bologna, Italy.,Dermatology Section, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, 40138, Bologna, Italy
| | - Leonardo Veneziano
- Dermatology, IRCCS di Policlinico Sant'Orsola Hospital, Bologna, Italy.,Dermatology Section, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, 40138, Bologna, Italy
| | - Chryssoula Papageorgiou
- Second Department of Dermatology, School of Medicine, Aristotle University, Thessaloniki, Greece
| | - Silvana Ciardo
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Rubegni
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria Alle Scotte Hospital, Viale Bracci 16, Siena, 53100, Italy
| | - Iris Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Annalisa Patrizi
- Dermatology, IRCCS di Policlinico Sant'Orsola Hospital, Bologna, Italy.,Dermatology Section, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, 40138, Bologna, Italy
| | - Caterina Longo
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy.,Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Bianchi
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133, Rome, Italy
| | - Giovanni Pellacani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy.,Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Farnetani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
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10
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Navarrete-Dechent C, Cordova M, Sahu A, Liopyris K, Rishpon A, Chen C, Rajadhyaksha M, Busam KJ, Marghoob AA, Chen CSJ. Optical imaging guided- 'precision' biopsy of skin tumors: a novel approach for targeted sampling and histopathologic correlation. Arch Dermatol Res 2021; 313:517-529. [PMID: 32844312 PMCID: PMC10185006 DOI: 10.1007/s00403-020-02126-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/02/2020] [Accepted: 08/08/2020] [Indexed: 01/25/2023]
Abstract
Dermoscopy and reflectance confocal microscopy (RCM) are two noninvasive, optical imaging tools used to facilitate clinical diagnosis. A biopsy technique that produces exact correlation with optical imaging features is not previously reported. To evaluate the applications of a novel feature-focused 'precision biopsy' technique that correlates clinical-dermoscopy-RCM findings with histopathology. This was a prospective case-series performed during August 2017 and June 2019 at a tertiary care cancer. We included consecutive patients requiring a precise dermoscopy-RCM-histopathologic correlation. We performed prebiopsy dermoscopy and both wide probe and handheld RCM of suspicious lesions. Features of interest were isolated with the aid of paper rings and a 2 mm punch biopsy was performed in the dermoscopy- or RCM-highlighted area. Tissue was processed either en face or with vertical sections. One-to-one correlation with histopathology was obtained. Twenty-three patients with 24 lesions were included in the study. The mean age was 64.6 years (range 22-91 years); there were 16 (69.6%) males, 14 (58.3%) lesions biopsied were on head and neck region. We achieved tissue-conservation diagnosis in 100% (24/24), 13 (54.2%) were clinically equivocal lesions, six (25%) were selected for 'feature correlation' of structures on dermoscopy or RCM, and five (20.8%) for 'correlation of new/unknown' RCM features seen on follow-up. The precision biopsy technique described herein is a novel method that facilitates direct histopathological correlation of dermoscopy and RCM features. With the aids of optical imaging devices, accurate diagnosis may be achieved by minimally invasive tissue extraction.
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Affiliation(s)
- Cristian Navarrete-Dechent
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
- Department of Dermatology, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Miguel Cordova
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Aditi Sahu
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Konstantinos Liopyris
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Ayelet Rishpon
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Curtis Chen
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Milind Rajadhyaksha
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Klaus J Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ashfaq A Marghoob
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Chih-Shan Jason Chen
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA.
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11
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Nie T, Jiang X, Zheng B, Zhang Y. Effect of reflectance confocal microscopy compared to dermoscopy in the diagnostic accuracy of lentigo maligna: A meta-analysis. Int J Clin Pract 2021; 75:e14346. [PMID: 33977614 DOI: 10.1111/ijcp.14346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/07/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Many concerns were raised about the sensitivity and specificity outcome of reflectance confocal microscopy compared to dermoscopy for the diagnosis of lentigo maligna. However, the reported relationships between their sensitivity and specificity were variable. Our meta-analysis was performed to clarify this relationship. METHODS A systematic literature search up to July 2020 was performed and six included studies had 479 subjects at the baseline with 294 undergoing lentigo maligna diagnoses. They were reporting relationships between sensitivity and specificity outcome of reflectance confocal microscopy compared to dermoscopy for the diagnosis of lentigo maligna. Mean difference (MD) with 95% confidence intervals (CIs) was calculated to evaluate the prognostic role of the sensitivity and specificity of reflectance confocal microscopy compared to dermoscopy for the diagnosis of lentigo maligna using the continuous method with a random or fixed-effect model. RESULTS Reflectance confocal microscopy was significantly related to higher specificity (MD, 19.10; 95% CI, 0.93-37.28, P = .04) compared to dermoscopy in lentigo maligna diagnosis. However, reflectance confocal microscopy was only relatively but not significantly related to higher sensitivity (MD, 14.56; 95% CI, 0.29-28.83, P = .05) compared to dermoscopy in lentigo maligna diagnosis. CONCLUSIONS Based on this meta-analysis, the reflectance confocal microscopy compared to dermoscopy in lentigo maligna diagnosis had a significantly higher specificity and relatively higher sensitivity. This relationship forces us to recommend reflectance confocal microscopy in lentigo maligna diagnosis for better outcomes and to avoid any possible false-negative results. Further studies are required.
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Affiliation(s)
- Tingfen Nie
- Department of Dermatology, Tianjin Baodi Hospital, Baodi Clinical College of Tianjin Medical University, Tianjin, China
| | - Xuebing Jiang
- Department of Cosmetology, Heilongjiang Academy of Chinese Medicine Sciences, Haerbin, Heilongjiang, China
| | - Baoyong Zheng
- Department of Dermatology, Tianjin Baodi Hospital, Baodi Clinical College of Tianjin Medical University, Tianjin, China
| | - Yanxiu Zhang
- Department of Dermatology, Tianjin Baodi Hospital, Baodi Clinical College of Tianjin Medical University, Tianjin, China
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12
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Star P, Rawson RV, Drummond M, Lo S, Scolyer RA, Guitera P. Lentigo maligna: defining margins and predictors of recurrence utilizing clinical, dermoscopic, confocal microscopy and histopathology features. J Eur Acad Dermatol Venereol 2021; 35:1811-1820. [PMID: 33998703 DOI: 10.1111/jdv.17349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lentigo maligna (LM) is a subtype of melanoma in situ with poorly defined margins and a high recurrence rate. The biological behaviour of LM appears to differ widely between cases, from biologically indolent to biologically active variants, with some patients experiencing multiple recurrences. It is not known whether this is secondary to inadequate margins, field cancerization or the innate biology of the lesion itself. OBJECTIVES (a) Describe the margins of LM in detail by analysing LM in three zones, that is centre, edge and surround using reflectance confocal microscopy (RCM) and histopathology; (b) ascertain association of histological distance of LM and atypical melanocytic hyperplasia from the surgical margin with multi-recurrent (MR) disease and (c) identify features (clinical, dermoscopy, RCM and histopathology) associated with MR LM. METHODS (1) Descriptive observational study comparing the centre, edge and surround of LM on histopathology and RCM; (2) retrospective cohort study comparing parameters associated with MR and non-recurrent (NR) LM. RESULTS 30 patients (median follow-up time 6.2 years) were included. On histopathology, confluent or near confluent lentiginous proliferation, melanocyte density >15 per 0.5 mm and adnexal spread were best for distinguishing surround from edge of LM. On RCM, predominant melanocytes, lentiginous proliferation and pleomorphism distinguished surround from centre/edge. MR patients had a median histological distance of LM from the surgical margin of 2mm (versus NR patients with an average distance of 4mm). MR patients had a greater proportion of more florid features, compared with NR on histopathology at both the centre and the edge but were similar in the surround. CONCLUSION These data may help pathologists and confocalists better define margins of LM. More florid features in MR patients, despite a similar background of sun-damaged skin, suggest the innate biology of the lesion rather than the field of cancerization may explain MR LM.
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Affiliation(s)
- P Star
- Melanoma Institute Australia (MIA), The University of Sydney, North Sydney, NSW, Australia.,Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - R V Rawson
- Melanoma Institute Australia (MIA), The University of Sydney, North Sydney, NSW, Australia.,Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Camperdown, Sydney, NSW, Australia
| | - M Drummond
- Melanoma Institute Australia (MIA), The University of Sydney, North Sydney, NSW, Australia.,Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - S Lo
- Melanoma Institute Australia (MIA), The University of Sydney, North Sydney, NSW, Australia.,Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - R A Scolyer
- Melanoma Institute Australia (MIA), The University of Sydney, North Sydney, NSW, Australia.,Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Camperdown, Sydney, NSW, Australia
| | - P Guitera
- Melanoma Institute Australia (MIA), The University of Sydney, North Sydney, NSW, Australia.,Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Sydney Melanoma Diagnostic Centre (SMDC), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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13
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Durkin JR, Tchanque-Fossuo CN, Rose AN, Elwood HR, Stepenaskie S, Barbosa NS. Surgical Margin Mapping of Melanoma In Situ Using In Vivo Reflectance Confocal Microscopy Mosaics. Dermatol Surg 2021; 47:605-608. [PMID: 33905390 DOI: 10.1097/dss.0000000000002926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Melanoma in situ (MIS) can have poorly defined borders and subclinical extension that makes margin control challenging. Reflectance confocal microscopy (RCM) is a promising noninvasive technique that can be used to assess subclinical spread. OBJECTIVE To optimize surgical margins of histology-proven MIS using RCM mosaics. MATERIALS AND METHODS Prospective review of 22 patients with histology-proven MIS who underwent RCM margin mapping prior to staged excision, between August 1, 2018, and August 13, 2020, at the Department of Dermatology, University of New Mexico, School of Medicine. RESULTS Twenty patients (91%) had tumor clearance on the first stage using a 3-mm surgical margin after confocal margin mapping. CONCLUSION Reflectance confocal microscopy margin mapping using the mosaic device tends to clear MIS in one stage, and the use of the handheld device may improve the accuracy for difficult anatomic areas. Current Procedural Terminology codes for RCM do not reflect the time required and complexity of the procedure. Reflectance confocal microscopy margin mapping prior to excision has the potential to decrease the number of stages needed for melanoma removal, reduce treatment time, and cost.
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Affiliation(s)
- John R Durkin
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | | | - Alexander N Rose
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Hillary R Elwood
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
- Tricore Reference Laboratories, Albuquerque, New Mexico
| | | | - Naiara S Barbosa
- Department of Dermatology, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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14
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Gao JM, Garioch JJ, Fadhil M, Tan E, Shah N, Moncrieff M. Planning slow Mohs excision margins for lentigo maligna: a retrospective nonrandomized cohort study comparing reflectance confocal microscopy margin mapping vs. visual inspection with dermoscopy. Br J Dermatol 2021; 184:1182-1183. [PMID: 33377177 DOI: 10.1111/bjd.19764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/23/2020] [Accepted: 12/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- J M Gao
- Department of Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Department of Dermatology, Royal Free London NHS Foundation Trust, London, UK
| | - J J Garioch
- Department of Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - M Fadhil
- Department of Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - E Tan
- Department of Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - N Shah
- Department of Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - M Moncrieff
- Norwich Medical School, University of East Anglia, Norwich, UK.,Department of Plastic Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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15
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Preoperative Evaluation through Dermoscopy and Reflectance Confocal Microscopy of the Lateral Excision Margins for Primary Basal Cell Carcinoma. Diagnostics (Basel) 2021; 11:diagnostics11010120. [PMID: 33466602 PMCID: PMC7828674 DOI: 10.3390/diagnostics11010120] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 12/30/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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16
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Elshot YS, Zupan-Kajcovski B, Klop WMC, Bekkenk MW, Crijns MB, de Rie MA, Balm AJM. Handheld reflectance confocal microscopy: Personalized and accurate presurgical delineation of lentigo maligna (melanoma). Head Neck 2020; 43:895-902. [PMID: 33231342 PMCID: PMC7984324 DOI: 10.1002/hed.26545] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 12/29/2022] Open
Abstract
Background The surgical treatment of lentigo maligna melanoma is associated with high rates of local recurrence. Handheld reflectance confocal microscopy (HH‐RCM) allows for in vivo presurgical detection of subclinical lentigo maligna (melanoma) (LM/LMM). Methods A single‐center retrospective study from December 2015 to July 2017. Frequency and extent of negative surgical margins, and the diagnostic accuracy of presurgical mapping by HH‐RCM was determined. Results Twenty‐six consecutive patients with LM/LMM were included. In 45.8%, HH‐RCM detected subclinical LM with a sensitivity of 0.90 and specificity of 0.86. The management was changed in two (7.7%) patients. Of the 24 remaining lesions, 95.8% were excised with negative margins with a mean histological margin of 3.1 and 5.3 mm for LM and LMM, respectively. At a mean follow‐up of 36.7 months, there was one (4.8%) confirmed recurrence. Conclusions Our method of presurgical delineation by HH‐RCM appears to provide a reliable method for the surgical treatment of LM/LMM with a limited rate of overtreatment.
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Affiliation(s)
- Yannick S Elshot
- Department of Dermatology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - William M C Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marcel W Bekkenk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marianne B Crijns
- Department of Dermatology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Menno A de Rie
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alfons J M Balm
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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17
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Estaji M, Mokhtari-Dizaji M, Movahedin M, Ghaffari Khaligh S. Non-invasive evaluation of elasticity of skin with the processing of ultrasound images during ultraviolet radiation: An animal photoaging model. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2020; 37:131-139. [PMID: 33098351 DOI: 10.1111/phpp.12622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 10/02/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to provide a non-invasive imaging method to evaluate the physical and mechanical parameters as a novelty method during skin photoaging. METHODS In order to evaluate the process of skin damage, 25 mice (C57BL6) were exposed to UVB radiation (0.03 mW/cm2 ), 5 times a week for 5 weeks. The thickness of the epidermal and dermal layers was measured weekly from the ultrasound images (40 MHz). The elastic parameters of the skin were estimated from the processing of the sequential ultrasound images with the motion detection algorithm during the injury generation process. RESULTS The thickening, Young modulus, and shear modulus of the dermal and epidermal layers during the UVB damage process significantly increased during the 5-week study period (P < .05). In addition, the percentage of changes in the thickness of the epidermal layer (0.22 ± 0.01 mm in day 0 to 0.37 ± 0.02 mm in day 35) and dermal layer (0.57 ± 0.05 mm in day 0 to 0.90 ± 0.08 mm in day 35) increased by 68% and 57%, respectively. Furthermore, Young modulus (154.41 ± 8.8 kPa) was 11 times more than that of non-irradiated skin (14.90 ± 2.2 kPa) and the shear modulus (2.33 ± 0.04 kPa) was 2.2 times more than non-irradiated skin (1.06 ± 0.04 kPa). CONCLUSION With processing the sequential ultrasound images and extracting the thickening, the elasticity of the skin layers can detect skin lesions by UVB radiation.
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Affiliation(s)
- Mohadese Estaji
- Department of Medical Physics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Manijhe Mokhtari-Dizaji
- Department of Medical Physics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Mansoureh Movahedin
- Department of Anatomy, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Sahar Ghaffari Khaligh
- Department of Pathobiology, Faculty of Veterinary Medicine, Semnan University, Semnan, Iran
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18
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Cinotti E, Belgrano V, Labeille B, Grivet D, Douchet C, Chauleur C, Cambazard F, Thomas A, Prade V, Tognetti L, Cartocci A, Rubegni P, Perrot JL. In vivo and ex vivo confocal microscopy for the evaluation of surgical margins of melanoma. JOURNAL OF BIOPHOTONICS 2020; 13:e202000179. [PMID: 32706484 DOI: 10.1002/jbio.202000179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 06/11/2023]
Abstract
We report the first series of melanomas (MMs) where the surgical margins were evaluated both by ex vivo confocal microscopy (EVCM) and in vivo reflectance confocal microscopy (RCM). We evaluated the surgical margins of 42 cutaneous MMs of lentigo maligna/lentigo maligna melanoma type and 2 mucosal MMs with EVCM. Cutaneous MMs also underwent RCM mapping. Imaging results were compared with histopathology. The rate of correct identification of the tumor margins (invaded or not invaded) was 97.6% for RCM (evaluations of cutaneous MMs) and 95.5% for EVCM (evaluations of both cutaneous and mucosal MMs). Our study showed that the MM extension is visible under EVCM and that the combination of in vivo RCM and EVCM can be a new strategy for the evaluation of surgical margins of MMs.
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Affiliation(s)
- Elisa Cinotti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Valerio Belgrano
- Department of Surgical Sciences and Integrated Diagnostics, San Martino University General Hospital, Genoa, Italy
| | - Bruno Labeille
- Department of Dermatology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Damien Grivet
- Department of Ophthalmology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Catherine Douchet
- Department of Pathology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Celine Chauleur
- Department of Gynecology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Frédéric Cambazard
- Department of Dermatology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Alix Thomas
- Department of Maxillofacial and Plastic Surgery, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Virginie Prade
- Department of Maxillofacial and Plastic Surgery, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Linda Tognetti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | | | - Pietro Rubegni
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Jean Luc Perrot
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
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19
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Franceschini C, Persechino F, Ardigò M. In Vivo Reflectance Confocal Microscopy in General Dermatology: How to Choose the Right Indication. Dermatol Pract Concept 2020; 10:e2020032. [PMID: 32363095 DOI: 10.5826/dpc.1002a32] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 12/31/2022] Open
Abstract
Reflectance confocal microscopy (RCM) is a high-resolution, noninvasive imaging technique being increasingly used as an aid to diagnosis in the dermatology setting. RCM is applied in the diagnosis of both melanoma and nonmelanoma skin tumors, but also in the interpretation and management of inflammatory skin diseases. Two different devices with different designs for specific indications are available in the market: a static and a handheld probe. Several clinical presentations of the lesion could affect the examination, such as the presence of ulceration or hyperkeratosis; moreover, the anatomical site can drive the probe selection as well as the effective indication to RCM examination. In this review article, indications for the use of RCM are described in detail with a schematic approach for practical purposes.
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Affiliation(s)
- Chiara Franceschini
- Clinical Dermatology Department, San Gallicano Dermatological Institute (IRCCS), Rome, Italy
| | - Flavia Persechino
- Clinical Dermatology Department, San Gallicano Dermatological Institute (IRCCS), Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Italy
| | - Marco Ardigò
- Clinical Dermatology Department, San Gallicano Dermatological Institute (IRCCS), Rome, Italy
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20
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Tognetti L, Cinotti E, Fiorani D, Couzan C, Perrot J, Rubegni P. Commentary on: Reflectance confocal microscopy and dermoscopy aid in evaluating repigmentation within or adjacent to lentigo maligna melanoma surgical scars. J Eur Acad Dermatol Venereol 2020; 34:13. [DOI: 10.1111/jdv.16046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L. Tognetti
- Dermatology Unit Department of Medical, Surgical and Neurosciences University of Siena Siena Italy
| | - E. Cinotti
- Dermatology Unit Department of Medical, Surgical and Neurosciences University of Siena Siena Italy
| | - D. Fiorani
- Dermatology Unit Department of Medical, Surgical and Neurosciences University of Siena Siena Italy
| | - C. Couzan
- Service de Dermatologie Hôpital Universitaire de Saint‐Etienne St. Etienne France
| | - J.L. Perrot
- Dermatology Unit Department of Medical, Surgical and Neurosciences University of Siena Siena Italy
| | - P. Rubegni
- Service de Dermatologie Hôpital Universitaire de Saint‐Etienne St. Etienne France
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21
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Atwan AA, Ziaj S, Mills CM. Defining Surgical Margins With Wood Lamp. Dermatol Pract Concept 2019; 10:e2020018. [PMID: 31921505 DOI: 10.5826/dpc.1001a18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2019] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ausama A Atwan
- Department of Dermatology, University Hospital of Wales, Cardiff, UK
| | - Stela Ziaj
- Department of Dermatology, Royal Gwent Hospital, Newport, UK
| | - Caroline M Mills
- Department of Dermatology, University Hospital of Wales, Cardiff, UK
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22
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Oh BH, Kim KH, Chung KY. Skin Imaging Using Ultrasound Imaging, Optical Coherence Tomography, Confocal Microscopy, and Two-Photon Microscopy in Cutaneous Oncology. Front Med (Lausanne) 2019; 6:274. [PMID: 31824956 PMCID: PMC6883721 DOI: 10.3389/fmed.2019.00274] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/11/2019] [Indexed: 12/21/2022] Open
Abstract
With the recognition of dermoscopy as a new medical technology and its available fee assessment in Korea comes an increased interest in imaging-based dermatological diagnosis. For the dermatologist, who treats benign tumors and malignant skin cancers, imaging-based evaluations can assist with determining the surgical method and future follow-up plans. The identification of the tumor's location and the existence of blood vessels can guide safe treatment and enable the use of minimal incisions. The recent development of high-resolution microscopy based on laser reflection has enabled observation of the skin at the cellular level. Despite the limitation of a shallow imaging depth, non-invasive light-based histopathologic examinations are being investigated as a rapid and pain-free process that would be appreciated by patients and feature reduced time from consultation to treatment. In the United States, the current procedural terminology billing code was established for reflectance confocal microscopy in 2016 and has been used for the skin cancer diagnosis ever since. In this review, we introduce the basic concepts and images of ultrasound imaging, optical coherence tomography, confocal microscopy, and two-photon microscopy and discuss how they can be utilized in the field of dermatological oncology.
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Affiliation(s)
- Byung Ho Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Hean Kim
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang-si, South Korea
| | - Kee Yang Chung
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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23
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Hamilko de Barros M, Conforti C, Giuffrida R, Seabra Resende FS, Di Meo N, Zalaudek I. Clinical usefulness of dermoscopy in the management of lentigo maligna melanoma treated with topical imiquimod: A case report. Dermatol Ther 2019; 32:e13048. [DOI: 10.1111/dth.13048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/23/2019] [Accepted: 07/29/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Mayara Hamilko de Barros
- Instituto de Dermatologia Professor Rubem David AzulayHospital Santa Casa de Misericórdia do Rio de Janeiro Rio de Janeiro Brazil
| | - Claudio Conforti
- Dermatology ClinicMaggiore Hospital, University of Trieste Trieste Italy
| | - Roberta Giuffrida
- Department of Clinical and Experimental Medicine, Section of DermatologyUniversity of Messina Messina Italy
| | | | - Nicola Di Meo
- Dermatology ClinicMaggiore Hospital, University of Trieste Trieste Italy
| | - Iris Zalaudek
- Dermatology ClinicMaggiore Hospital, University of Trieste Trieste Italy
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24
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Cinotti E, Fiorani D, Labeille B, Gonzalez S, Debarbieux S, Agozzino M, Ardigò M, Lacarrubba F, Farnetani F, Carrera C, Cevenini G, Le Duff F, Tognetti L, Pellacani G, Rubegni P, Perrot JL. The integration of dermoscopy and reflectance confocal microscopy improves the diagnosis of lentigo maligna. J Eur Acad Dermatol Venereol 2019; 33:e372-e374. [PMID: 31074539 DOI: 10.1111/jdv.15669] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- E Cinotti
- Dermatology Section, Department of Medical, Surgical and Neurological Science, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - D Fiorani
- Dermatology Section, Department of Medical, Surgical and Neurological Science, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - B Labeille
- Department of Dermatology, University Hospital of St-Etienne, Saint-Etienne, France
| | - S Gonzalez
- Medicine and Medical Specialities Department, Alcalá University, Madrid, Spain
| | - S Debarbieux
- Departments of Dermatology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - M Agozzino
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Ardigò
- Clinical Dermatology, San Gallicano Dermatological Institute, Rome, Italy
| | - F Lacarrubba
- Dermatology Clinic, University of Catania, Catania, Italy
| | - F Farnetani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - C Carrera
- Melanoma Unit, Department of Dermatology, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona University, Barcelona, Spain
| | - G Cevenini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - F Le Duff
- Department of Dermatology, Clinical Research Center, Hopital Archet 2, Nice, France
| | - L Tognetti
- Dermatology Section, Department of Medical, Surgical and Neurological Science, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - G Pellacani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - P Rubegni
- Dermatology Section, Department of Medical, Surgical and Neurological Science, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - J L Perrot
- Department of Dermatology, University Hospital of St-Etienne, Saint-Etienne, France
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