WWW Medscape PDF

11/4/2015
www.medscape.com/viewarticle/582894_print
www.medscape.com
NoninvasiveDiagnosisofNonmelanomaSkin
Cancer:FocusonReflectanceConfocal
Microscopy
MartinaUlrichSusanneAstnerEggertStockflethJoachimRwertHuber
ExpertRevDermatol.20083(5):557567.
AbstractandIntroduction
Abstract
Nonmelanomaskincancer(NMSC)representsthemostcommoncutaneousneoplasmsand,inthepastdecade,
nonsurgicaltreatmentmodalitieshavebeenestablishedaspartofthemanagementofNMSC.Recently,novel
noninvasivediagnosticmodalitieshavebeendevelopedand,ofthese,reflectanceconfocalmicroscopy(RCM)
offersimagingoftheskininvivowithcellularresolution.NMSCs,includingbasalcellcarcinoma,actinickeratosis
andsquamouscellcarcinoma,havebeenevaluatedbyRCM,anddiagnosticcriteriaweredefined.Bycorrelation
withroutinehistologysectionsandincomparisonwithnormalskin,RCMshowedhighsensitivityandspecificity
values.RCMallowsthenoninvasiveevaluationofavarietyofskinconditions,includingNMSC.RCMmayaidinthe
diagnosisanddifferentialdiagnosisofNMSC,aswellasinmonitoringoftreatmentresponsetotopicaltreatment
modalities.Therefore,RCMappearstobeapromisingdiagnostictoolwithmanypossibleapplicationsin
dermatology.
Introduction
Thedifferentialdiagnosisofinflammatoryandneoplasticskindisordersmayoftenbeobtainedbasedonclinical
examination,sinceabnormalskinfindingsarereadilyamenabletovisualinspection.However,thedifferential
diagnosismaybebroadandbiopsywithsubsequenthistologyisoftenperformedforconfirmation.Therefore,
histologyremainsthecurrentdiagnostic'goldstandard'indermatology.Skincancerbiopsiesareroutinely
performedforaccuratediagnosticclassificationandoptimizedtumormanagement.
However,skinbiopsiesmaybeassociatedwithsignificantdisadvantagesastheprocedureitselfisinvasive,thereby
leadingtopainandscarformation.Histologicalprocessingandstaininginduceirreversibletissuealterationsand
mayultimatelyresultinartefacts.Ahistologicalevaluationperdefinitionprecludesaninvivoexaminationanddoes
notpermitrepeatedevaluationsovertime.Followinginitialdiagnosisbybiopsy,asecondsurgicalprocedureis
oftenrequiredforcompleteremovalofthelesion.
Inthepastdecades,anumberofadjunctdiagnostictechniqueshavebeenintroducedindermatology,including,
amongothers,dermoscopy,highfrequencyultrasoundandopticalcoherencetomography.Thesemodalitiesallow
thenoninvasiveevaluationofskinwithdifferencesinpenetrationdepthandresolution,butdonotvisualizecellular
details.Recently,reflectanceconfocalmicroscopy(RCM)hasbeenevaluatedforavarietyofinflammatoryand
neoplasticskinconditions.Incontrasttoothernoninvasiveimagingtechniques,RCMallowstheassessmentof
cellulardetailsandmicrostructuresoftheskinwitharesolutioncomparabletoroutinehistologysections.Herein,we
presentanoverviewofRCMwithspecialregardtononmelanomaskincancer(NMSC).
NMSC:RecentDevelopmentsinEpidemiologyandManagement
Nonmelanomaskincanceristhemostcommoncancerinhumansandtheincidenceisincreasingcontinuously.
ThemostimportantriskfactorinthepathogenesisofNMSCischronicultravioletradiation.Thepastdecadeshave
shownasignificantchangeofsunexposurehabitsinthegeneralpopulation,andtheincreaseofvacationaland
recreationalsunexposurehascontributedtothecurrentepidemiologicdevelopments.Furthermore,ahigherrateof
skincancerincidenceinyoungpatientshasbeenreported,wherebythemajorityofcasesdevelopmultipletumors.
Histologically,twomajorformsofNMSChavetobedistinguished:basalcellcarcinoma(BCC)andsquamouscell
carcinoma(SCC).
http://www.medscape.com/viewarticle/582894_print
1/16
11/4/2015
BasalCellCarcinoma
Thisisthemostfrequentinvasiveskincancerinhumansanditsincidenceisrisingcontinuouslyworldwide.Recent
datafromGreatBritainreportanannualincidenceofup153.9per100,000personyears,withBCCbeingmore
commoninmales. [1]Themostimportantriskfactorisultravioletradiation,andupto80%ofcasesdeveloponthe
headandneckarea.However,BCCmayalsooccuronotherlocations,suchasthetrunkandtheextremities,and
isalwayslimitedtoareaswithahighdensityofpilosebaceousunits.ThreemajorvariantsofBCCcanbe
distinguishedclinicallyandhistologically,namely,nodularBCC,superficialBCCandmorpheaformBCC.Nodular
BCCclinicallypresentsasskincoloredtoerythematouspapulesornoduleswithapearlyorwaxyappearancethat
maydevelopcentralulceration.SuperficialBCCischaracterizedbyerythematoustobrownishplaqueswithslightly
elevatednodularborderandpotentialcrusting.TheclinicaldiagnosisofsclerodermiformBCCmaybedifficultasit
oftenresemblesscars.Fordecades,excisionalsurgeryhasbeenthegoldstandardoftreatmentofBCCandstill
remainsthetreatmentofchoiceforBCCinfaciallocationandnodulartypeBCC.However,recentlynoninvasive
treatmentmodalitieshavebeendevelopedandshowntobeeffectiveforBCC.Theseincludetopicalimiquimod5%
creamandphotodynamictherapy. [24]
SquamousCellCarcinoma
Squamouscellcarcinomaisdefinedasmalignantneoplasiaofepidermalkeratinocytes.IncontrasttoBCC,which
usuallydevelopsdenovo,squamouscellneoplasiarepresentsacontinuousprocessfromSCCinsitu,namely,
actinickeratoses(AKs)toinvasiveSCC.HistopathologicgradingofAKshasbeendescribed,referringtothe
developmentofSCCfromatypicalepidermalkeratinocytes.Therefore,areclassificationhasbeenproposedthat
definesAKasSCCinsitu. [5,6]Recently,thetermsearlyinsituSCCtypeAKI,IIandIIIhavebeensuggestedfor
improveddescriptionofthelesions,inanefforttooptimizethetherapeuticmanagementofAKsbasedontheir
degreeofatypia. [7]
Clinically,AKspresentaserythematoustobrownishplaqueswithoverlyinghyperkeratosisonsunexposedskin
sites.MultipleAKsusuallyoccuronactinicallydamagedskin,aphenomenonthathasbeendescribedbytheterm
'fieldcancerization'. [8]Intheseareas,multipleAKsofdifferentgradesarepresentandinvasiveSCCmaydevelop.
Followinglongstandingsunexposure,substantialatypiaofkeratinocytesmayalsooccurinclinicallynormalskin,
suggestingthepresenceofsubclinicalAK.Thisfindinghasfurtherbeencorroboratedbytheappearanceof
'subclinicallesions'inareasoftreatmentwithimiquimodcream5%forAKinserialclinicalstudies.
Withouttreatment,AKmayprogressintoinvasiveSCCinapproximately510%ofcases, [9]withahigherriskof
invasivegrowthinpatientsonchronicimmunosuppression.Atthepresenttime,itisnotpossibletopredictwhich
lesionwillprogressandatwhichtimepointthismayhappen,eitherbyclinicalorhistologicalexamination.
Therefore,treatmentofallAKsisrecommended. [10]Clinically,SCCgenerallyappearsasahyperkeratotic,
infiltrativeplaqueornodulethatmayulcerateorhaveahistoryoffrequentirritationorbleeding.Clinical
differentiationofSCCfromAKmaybedifficult,andbiopsywithhistologicalexaminationisrequiredwhenindoubt.
DiagnosticStandardsforNMSC
ClinicalExamination
ThefirststepinevaluatingalesionsuspiciousforNMSCistheclinicalexamination.However,thediagnostic
accuracyisdifficulttoassessanddependsontheeducationallevelandtrainingoftheobserver.Reported
sensitivityofclinicaldiagnosisvariesfrom56to90%andspecificityfrom75to90%. [11]
Dermoscopy
Inordertoimprovediagnosticaccuracy,severalnoninvasivetechnologieshavebeenintroducedandevaluated.
Dermoscopyiswellestablishedforthediagnosisofpigmentedskinlesionsandhasbeenshowntoimprove
diagnosticaccuracyformalignantmelanoma.Dermoscopyallowsthenoninvasiveevaluationoftheskinsurface
with10100timesmagnification.TheuseforNMSChasonlyrecentlybeeninvestigatedandmainlyfocusedon
BCCwithspecialregardtothedifferentiationfrommalignantmelanoma.Diagnosticcriteriafordermoscopic
evaluationofpigmentedBCChavebeendefinedbyMenziesandincludetheabsenceofpigmentednetworkand
thepresenceofoneofthefollowingcriteria:mapleleaflikeareas,spokewheelareas,largebluegrayovoidnests,
2/16
11/4/2015
largebluegrayglobules,arborizingteleangiectasiaandulceration.Usingthismodel,asensitivityof93%forBCC
andaspecificityof89%hasbeenreportedforBCCwhendifferentiatingitfrommalignantmelanoma. [12]A
subsequentstudyevaluatedtheinterobserveragreementofthesefeaturesandconfirmedthereproducibilityofthe
method. [13]
WhereasthevalueofdermoscopyforpigmentedBCChasbeenextensivelystudied,theevaluationof
nonpigmentedBCChasonlybeenthesubjectofrecentstudies.Thesehavemainlyfocusedontheevaluationof
vascularpatternsandhavedescribedarborizingvesselsasthemostprominentfeatureofnonpigmentednodular
BCC.Argenzianoetal.reportedarborizingvesselsin82%ofBCCwithapositivepredictivevalueof94%. [14]A
studyevaluatingthedermoscopyfindingsof24superficialBCCsrevealedthatthemajorityofthesestumorsdonot
showarborizingvessels,butshort,fineteleangietasiasin91.7%ofcases. [15]
DermoscopiccriteriaofSCChavebeendescribedinpreliminarystudies,includingglomerularvesselsandscaly
surface.However,futureinvestigationsmustbeperformedinordertodefinethesensitivityandspecificityofthese
findings.
HistologicalExamination
Theevaluationofasampleobtainedbyskinbiopsyisconsideredasthecurrentgoldstandardinthediagnosisof
NMSC.Biopsymaybeperformedindifferenttechniques,suchaspunch,shaveorexcisionalbiopsy.Local
anesthesiaisnecessaryandscarformationresults.Sideeffectsincludepain,bleedingorwoundinfection.The
abilityofcorrectdiagnosisbyskinbiopsyandhistologyisdependentonthephysicianthataquiresthebiopsy,as
wellasontheabilityofthedermatopathologist.Studieshavemainlyfocusedontheevaluationofinterobserver
differences,andconcordanceratesof0.90intraclasscorrelationcoefficient(ICC)havebeenreportedforthe
histologicaldiagnosisofAKsandSCC. [16]
NovelDiagnosticTechniques:ReflectanceConfocalMicroscopy
Inthepastdecade,anumberofadjunctdiagnostictechniqueshavebeendevelopedand,toadifferentextent,
evaluatedfortheirapplicabilityinNMSCdiagnosis.Theseinclude,amongothers,opticalcoherencetomography,
bispectralfluorescenceimaging,ramanmicroscopy,fluorescenceimaging,multiphotonimaging,fluorescence
confocalmicroscopyandRCM. [1725]Amongthem,fluorescenceandRCMaretheonlytechniquesthatallowan
evaluationofcellulardetailsatanearhistologicresolution. [2527]Fluorescencemodeconfocalmicroscopyrequires
theinjectionofafluorescentdyepriortoexamination,thusmakingtheexaminationminimallyinvasivewithlimited
examinationtimeowingtodepletionoffluorescentdye.TheprincipleofRCMiscomparabletoultrasoundbut,
insteadofultrasoundwaves,thesystemisbasedontheopticalreflectivity.Apointlightsourceisusedtoilluminate
asmallspotwithinthetissue.Thelightisreflectedfromthetissueandconductedthroughasmallpinholeontoa
detector(theopticalprincipleofRCMisshowninFigure1).Forvisualizationofalargerhorizontalplanewithinthe
tissue,thepointlightsourceisscannedacrossthetissueunderinvestigation.TheresolutionofRCMisdependent
onthewavelengthofthelightsourceandthenumericalapertureoftheobjectivelens.Thecommerciallyavailable
confocalmicroscope(Vivascope1500,MavigGmbHMunichGermanyLucidInc.,Rochester,NY,USA)usesa
830nmdiodelaseranda30objectivelenswithanumericalapertureof0.9.Themaximumlaserpowerofthe
systemis40mW.Withanaxialresolutionof35mandalateralresolutionofapproximately1m,RCMimages
arecomparabletoroutinehistologysections.Thepenetrationdepthreachesupto300m,whichcorrespondsto
theleveloftheupperreticulardermis.Theuseofalaserwithalongerwavelengthwouldenhancethepenetration,
butalsoresultinanimpairedresolution.Unliketheverticalsectionsofroutinehistology,theimagesobtainedby
RCMarehorizontal(enface).Furthermore,RCMimagesaregrayscale.ThecontrastprovidedbyRCMisbasedon
thedifferentrefractiveindicesofcutaneouschromophores:melanin,hemoglobinandcellularmicrostructures
providethecontrastthatisnecessaryforthemorphologicdescriptionofthedifferentskinlayers.Normalskinshows
characteristicfindingsonRCMexaminationwitharrangementofkeratinocytesinaregular,honeycomblike
architecturebeingthemoststrikingfeature.Thecellsvaryinsizefrom10to30minthestratumcorneum,20to
25minthestratumgranulosumandasmallercellsizeof1525minthestratumspinosum.Othermorphological
structuresoftheskin,suchasdermalpapillae,adnexalstructures(hairfollicles,sebaceousglandsandeccrine
ducts),collagenandbloodvessels,mayalsobevisualizedbyRCMandcorrelatedtoroutinehistologysections. [27
29]Recently,theRCMdevicehasbeenequippedwithadermoscopictool,whichfurtherenhancesthediagnostic
propertyofthedeviceandallowsthedirectRCMexaminationofareassuspiciousondermoscopy.
3/16
11/4/2015
Figure1.
Simplifiedopticalprincipleofreflectanceconfocalmicroscopyillustratingthewayofthelightfromthepointlight
sourcetotheskinandontothedetector.Informationfrom[27].
EvaluationwithRCMMayBePerformedInVivoandExVivo
WithregardtoNMSCexvivoRCMhasmainlybeenusedinthesettingofMohsmicrographicsurgery.Respective
clinicalstudieshaveshowntheapplicabilityofRCMtodetectcharacteristicfeaturesofBCCandSCCinexvivo
sections. [3032]Limitationsincludedthedetectionofsmalltumorislandsandthedetectionofsclerosingand
infiltrativeBCC. [30,33]ArecentpublicationdescribedtherapiddetectionofBCCinthesettingofMohs
micrographicsurgerybyusingconfocalmosaics. [33]ExvivoRCMmay,therefore,beapotentialguidefor
micrographicsurgeryandmayacceleratethesurgicalprocedurebyavoidingtheneedforfrozenhistologysections.
Theinvivoapplicationisofspecialinterestforthediagnosisofskincancer,sincediagnosismaybeobtained
noninvasivelyandimmediatelyatthetimeoftheexaminationwithouttissueremoval.Furthermore,serial
evaluationsofthesamelesionmaybeperformedoveraperiodoftime,wherebytherapeuticeffectsmaybe
documented.
Asthepenetrationdepthislimitedtoamaximumofapproximately300m,cutaneousdisordersthataffectthe
epidermalandtheupperdermalcompartmentareespeciallyamenableforRCMevaluation.Similartoother
noninvasivediagnostictechniques,themajorityofperformedstudieshavefocusedontheevaluationofpigmented
lesions.However,NMSChasbeenthesubjectofrecentstudies,wherebydiagnosticRCMparametershavebeen
establishedandsensitivityandspecificityanalysesforbothBCCandAKwereperformed.
BasalCellCarcinoma
Inarecentanalysis,fivemajorcriteriafortheRCMdiagnosisofBCChavebeendefined,includingelongated
monomorphicbasaloidnuclei,polarizationofthesenucleialongthesameaxis,prominentinflammatoryinfiltrate,
increaseddermalvasculaturewithtortuosityofthetumorvesselsandpleomorphismoftheoverlyingepidermiswith
lossofnormalhoneycombpattern().Thepresenceofpolarizednucleishowedthehighestsensitivityand
specificityof91.6and97%,respectively,withthepresenceoffourormorecriteriabyRCMthediagnosisofBCC
hadasensitivityof82.9%andaspecificityof95.7%. [34]Inthisstudy,minorvariationsweredescribedregardingthe
differentsubtypesofBCC(nodular,superficialandinfiltrativeBCC).
[19]ThevariationsofRCMfeatureswithregard
4/16
11/4/2015
differentsubtypesofBCC(nodular,superficialandinfiltrativeBCC). [19]ThevariationsofRCMfeatureswithregard
toBCCsubtypesarenowaddressed.
Box1.ReflectanceConfocalMicroscopyFeaturesofActinicKeratosisandBasalCellCarcinoma
CommonReflectanceConfocalMicroscopyFeaturesofBasalCellCarcinoma
StratumCorneum
Parakeratosismaybepresent
Superficialdisruptioninulceratedbasalcellcarcinoma
StratumGranulosumandSpinosum
Slightatypiawithdisruptionofhoneycombpatternandpleomorphismmaybepresent
StratumBasal/DermoepidermalJunction
Monomorphiccellswithelongatednuclei
Polarizationoftheseelongatednucleialongthesameaxis
Streaming:alltumorcellsareorientedalongthesameaxis
Palisading:peripheralcellsinthetumornoduleareorientedinaparallelmannerforminganouterline
perpendiculartothestroma
Dermis
Increasedvascularity
Vesselswithlargecaliberandhighbloodflow
Increasedtortuosity
Inflammatoryinfiltratecomposedofsmallhighlyrefractilearoundcells
Monomorphicpolarizedcellsand/orformationoftumornodulesinnodularbasalcellcarcinoma
CommonReflectanceConfocalMicroscopyFeaturesofActinicKeratosis
StratumCorneum
Superficialdisruptionwithsingledetachedpolygonalcells
Parakeratosis
Keratinocyteatypiawithdisruptionofhoneycombpattern
Pleomorphismofkeratinocyteswithvariationinsizeandshapeofcellsandnuclei
5/16
11/4/2015
Atypia/pleomorphism
Dermis
Mildtomoderatedilatationofvesseldiameter
Increasedtortuosity
Solarelastosiswithamorphousmoderatelyrefractilelacymaterialadjacenttoabnormalfibroticbundles
BasalCellCarcinoma
NodularBCC
Besidestheaforementionedcriteria,nodularBCCadditionallypresentsnestsofaggregatedtumorcellsinthe
upperdermis,whichareoftenadjacenttolargeanddilatedbloodvessels.Byapplyingthehorizontalmapping
functionontheleveloftheupperdermis,therevealingmosaicsshowcharacteristicmorphologywithmultipletumor
nodulesordigitiformstructures,whichareseparatedfromthedermalcollagenbyfibrosis.Thetumoraggregates
themselvesarecharacterizedbytheformationofcrowdedcellswithvariablerefractivity.Thecellsintheperiphery
ofthetumornoduleusuallyshowperipheralpalisading,aswellaselongatednuclei.Peritumoralcleftingcanbe
visualizedbyconfocalmicroscopyasdarkspacessurroundingthetumornodules,whichcorrespondtothoseclefts
seenonroutinehistology.Variableinflammationdefinedbythepresenceofsmall,highlyrefractivecellsinthe
dermiscanbeseen.TheRCMfeaturesofnodularBCCarepresentedinFigure2.
6/16
11/4/2015
Figure2.
Reflectanceconfocalmicroscopyimagesofbasalcellcarcinoma.(A)Nestsoftumorcellsinthedermis,elongated
shapeofcellsandnuclei(arrow),darkspacesinbetweentumornodulesandsurroundingcollagencorrespondto
cleftsonhistopathology.(B)Large,dilatedbloodvesselsadjacenttodermaltumornest(arrow)withhighly
reflectivewhitecellsinthecenterofthevesselcorrespondtoerythrocytes.(C)Polarizationofcells(arrow).(D)
Representativehematoxylinandeosinhistologyofbasalcellcarcinomawithnestsofbasaloidtumorcells,clefting
andbloodvesseldilatation(arrow).
SuperficialBCC
InsuperficialBCC,thepathologyisconcentratedonthelowerpartoftheepidermisandthesuperficialdermis.
Aggregationofpolarizedcellswithelongatednucleiwithorientationalongthesameaxiscanbevisualizedinthe
basalcelllayerandthesuperficialdermis.Otherfeatures,includingincreaseddilatationandtortuosityofthe
vasculatureandvariabledegreeofinflammatorycells,mayalsobeseen.
InfiltrativeBCC
ImagingofinfiltrativeBCCbyRCMshowsaggregationofmonomorphiccellswithelongatednucleiintheupper
dermis,surroundedbyadenseandcellrichstroma.Peripheralpalisadingisusuallyabsentandtheborders
betweentumorcellaggregatesandstromaarepoorlydefined. [30,34]ThediagnosisofinfiltrativeBCCremainsmore
challengingwhencomparedwithnodularandsuperficialBCCasthefeaturesareoftenlesspronounced. [30]
7/16
11/4/2015
challengingwhencomparedwithnodularandsuperficialBCCasthefeaturesareoftenlesspronounced. [30]
PigmentedBCC
PigmentedvariantsofBCCmaybeseeninallpreviouslydescribedsubtypes.OnRCMimaging,dendritichighly
refractivecellsintheupperdermiscanbevisualized,correspondingtomelanocytesonhistopathologicexam.
Furthermore,brightovaltostellatestructureswithindistinctborderscanbeimagedbyRCM,correlatingto
melanophagesonroutinehistology. [35,36]Thepresenceofhighlyrefractivecellsmay,initially,bemisleadingby
suggestingthatthelesionbemelanocytic,butthepresenceofspecificBCCfeatures(e.g.,monomorphiccellswith
elongatednucleiorpolarization)confirmthediagnosisofBCC.
ResidualorRecurrentBCC
WhenusingRCMinclinicalpractice,theinvestigatormaybefacedwiththequestionofresidualorrecurrentBCC
afterpreviousexcision.Todate,nostudieshavebeenperformedregardingthisquestion.Accordingtoour
experience,itmightbeverychallengingtodetectresidualorrecurrentBCCinsurroundingscartissue.The
formationofthecollagenbundleswithinthescarmayresemblepolarizationalongthesameaxisorperitumoral
fibrosis(Figure3).
Figure3.
8/16
11/4/2015
Representativereflectanceconfocalmicroscopyimagesofahypertrophicscarafterbasalcellcarcinomaexcision.
Theformationofthecollagenalongthesameaxisresemblesthearrangementoftumourcellsinbasalcell
carcinoma(streaming).
ActinicKeratosis
ActinickeratosishistologicallyrepresentsaSCCinsituandshowssimilarcellularandmorphologicalchanges.
InvasiveSCCmayonlybedistinguishedfromAKbyinfiltrationthroughthebasementmembraneintothedermis.
HistologicalcriteriaofAKincludeparakeratosis,keratinocyteatypia,lossofnormalmaturationandarchitectureof
theepidermisandpleomorphismofcellsandnuclei.ApreliminarystudybyAghassietal.analyzedanddescribed
RCMcriteriaofAK,whichcorrespondedwelltohistologicalfindings. [37]Recentstudieshaveevaluatedthe
sensitivityandspecificity,andvaluesgreaterthan80%werereportedintwoindependentstudieswiththehighest
ratesforepidermalpleomorphism,architecturaldisruption/lossofnormalhoneycombpatternandcellularatypia.On
RCMexamination,disruptionofthestratumcorneumisvisualizedbydetachedhighlyrefractivecellswithpolygonal
shape.Thepresenceofdarkroundareasinthecenterofthecorneocytescorrespondstoparakeratosis.Onthe
levelofthestratumgranulosumandspinosumatypia,pleomorphismofthecellscanbedetectedbyvariationof
shape,sizeandarrangementofthekeratinocytes. [3840]Dependingonthegradeofdysplasia(AKgradeI,IIorIII),
theatypiainvolvesthebasalcelllayerandstratumspinosuminmildtomoderate(AKgradeIandII)orallthree
layers,includingthestratumgranulosum(AKIII).Inthedermis,prominentbundlesofcollagenandlacelike
amorphousmaterialcorrespondingtosolarelastosiscanbevisualizedbesidesdilatedbloodvesselsandvariable
inflammatoryinfiltrate.RepresentativeRCMimagesofAKandcorrespondinghematoxylinandeosinhistologyare
showninFigure4&.
Box1.ReflectanceConfocalMicroscopyFeaturesofActinicKeratosisandBasalCellCarcinoma
CommonReflectanceConfocalMicroscopyFeaturesofBasalCellCarcinoma
StratumCorneum
Parakeratosismaybepresent
Superficialdisruptioninulceratedbasalcellcarcinoma
StratumGranulosumandSpinosum
Slightatypiawithdisruptionofhoneycombpatternandpleomorphismmaybepresent
Monomorphiccellswithelongatednuclei
Polarizationoftheseelongatednucleialongthesameaxis
Streaming:alltumorcellsareorientedalongthesameaxis
Palisading:peripheralcellsinthetumornoduleareorientedinaparallelmannerforminganouterline
perpendiculartothestroma
Dermis
Vesselswithlargecaliberandhighbloodflow
9/16
11/4/2015
Increasedtortuosity
Inflammatoryinfiltratecomposedofsmallhighlyrefractilearoundcells
Monomorphicpolarizedcellsand/orformationoftumornodulesinnodularbasalcellcarcinoma
CommonReflectanceConfocalMicroscopyFeaturesofActinicKeratosis
StratumCorneum
Superficialdisruptionwithsingledetachedpolygonalcells
Parakeratosis
Keratinocyteatypiawithdisruptionofhoneycombpattern
Pleomorphismofkeratinocyteswithvariationinsizeandshapeofcellsandnuclei
Atypia/pleomorphism
Dermis
Mildtomoderatedilatationofvesseldiameter
Increasedtortuosity
Solarelastosiswithamorphousmoderatelyrefractilelacymaterialadjacenttoabnormalfibroticbundles
10/16
11/4/2015
Figure4.
Reflectanceconfocalmicroscopyimagesofactinickeratosis.(A&B)Lossofnormalepidermalhoneycombpattern,
architecturaldiarray,cellularatypiaandpleomorphism.(C)Markedsolarelastosisintheupperdermis.(D)
Representativehematoxylinandeosinhistologyofactinickeratoseswithproliferationofatypicalkeratinocytes
(crowding).
DifferenceshavebeenobservedregardingthereliabilityofcorrectdiagnosisdependingonthelevelofRCM
traininghighconcordancerateswereachievedinexperiencedRCMobservers. [3840]
InvasiveSCC
ThedifficultyofdistinguishingearlyinvasiveSCCfromAKhasalreadybeenthesubjectofthepreliminarystudy
publishedbyAghassietal.. [37]Differentfactorscontributetothefailureofdetectingearlysquamouscellinvasion:
impairedresolutionintheupperdermis,hyperkeratosis(whichadditionallyreducesresolution)andthefactthatthe
imagesobtainedbyRCMarehorizontal.However,therearesomefeaturesindicatinginvasion.Anylesionwithfull
thicknessatypiaofthewholeepidermiswithparakeratosispresentintheareaoftheacrosyringia(hairfollicles)
shouldbepaidspecialattentionandrequiresbiopsyorexcision.Futurestudiesmustproveifthesefeaturesmight
besensitiveandspecificinthedifferentiationofAKandearlyinvasiveSCC.
IncasesoffullydevelopedSCC,thediagnosisisnotaschallenging.Besidesepidermalchanges,atypical
aggregatesofkeratinocytesmaybevisualizedinthedermis. [41]
11/16
11/4/2015
Discussion
Noveldiagnosticimagingtoolshavebeenintroducedandevaluatedforavarietyofcutaneousdiseases,including
NMSC.RCMofferstheevaluationofmicrostructuresoftheskinincellularresolutionandtheimagesobtainedare
comparabletoroutinehistologysections.RCMoffersseveraladvantagesforthedermatologistastheimagingis
noninvasive,painless,invivoandallowsfortheevaluationoftheskinwithoutprocessingartefacts.Therefore,
monitoringofthesamelesionoveraperiodoftimecanbeperformedandchangescanbevisualized.Inthis
regard,treatmenteffectsbecomevisibleandmorphologicalevaluationofatherapeutichealingprocessmaybe
seen.Treatmentofimiquimod5%forBCChasbeenevaluatedsuccessfullyandclearancehasbeenconfirmedby
RCM. [42,43]Recently,studieshavedescribedthefeaturesoftrichoepitheliomaasadifferentialofBCCand
disseminatedsuperficialactinicporokeratosisasadifferentialofAK. [44,45]
However,thereareanumberoftechnicalandopticallimitationsthatremaintobeaddressed.Amongthemisthe
restrictedpenetrationdepthofapproximately300m,whichdoesnotallowthevisualizationofcutaneous
structuresorpathologicchangesofdeeperpartsofthedermis.Furthermore,thehorizontalimagesimpedethe
evaluationofverticalinvasionandtumordepth.Inhyperkeratoticlesions,suchasAK,invasiveSCCor
keratoacanthoma,thepenetrationislimitedowingtoabsorptionandscatteringoflight.Inthesecases,careful
curettageofthehyperkeratoticscalemayclearlyimprovevisualizationofthelesion.Thecurrentcontactdeviceof
thecommerciallyavailablesystemalsohassomelimitations.Thediameterof3cmdoesnotallowforthe
examinationofnonflatsurfaces,suchasthelateralpartsofthenoseorpartsoftheear.Smallerskincontactring
devicesarecurrentlybeingtestedforclinicalapplicability.Inaddition,anewhandhelddevicehasrecentlybeen
introduced,whichmayhelptoovercometheseproblemsinthefuture.
Reflectanceconfocalmicroscopyisanemergingtechniqueand,althoughspecificfeaturesofAK,BCC,melanoma
andmanyothercutaneousdiseaseshavebeendescribed,imageinterpretationmaysometimesbedifficult.For
example,cellsofdendriticappearancemayeitherrepresentmelanocytes,melanophagesorLangerhans'cells.
Similartothemajorityofnoveltechniques,trainingisneededfortheperformanceoftheprocedureand
interpretationoftheimages.
Sofar,RCMhasbeenperformedmainlyinacademicmedicalcentersandresearchsettings.However,theoption
ofnoninvasiveandinvivoevaluationoftheskinmayrepresentapowerfuladjunctdiagnostictoolforusein
everydayclinicalpractice.Clinicalapplicationsincludeavarietyofsituations.Thefeaturesofmanyinflammatory
andneoplasticskinconditionshavealreadybeendescribedandmaybedifferentiatedbyRCM.Therapeuticeffects
maybeidentifiedandmonitored,andefficacycanbeassessedbyRCMimaging.Furthermore,RCMmayaidin
identifyingthemostrepresentativesiteforbiopsywithinaselectedlesion,therebyavoidingsamplingerrorsorfalse
negativetestresults.Inthisregard,thedifferentialdiagnosisofmelanomafrombenignnevicurrentlyrepresents
thefieldofgreatestinterest.WithregardtoNMSC,furtherapplicationsarepossibleandreasonable.The
differentiationofBCCsubtypesmaybeperformedandtreatmentdecisionsmaybeinfluencedbyRCMtoeither
surgical(nodularandsclerosingtype)ortopicaltreatment(superficialtype).PigmentedBCCmaybedifferentiated
frommalignantmelanomaorotherpigmentedlesionsandeasetreatmentplanning.Diagnosticbiopsymaybe
avoidedinselectedpatients,allowingtheadequatesurgicalproceduretobeperformedwithoutfurtherdelay.In
AKs,theextentofactinicdamagemaybeevaluatedbeyondclinicallyvisibleAKsandtheidentificationof
subclinicallesionsmaydeterminethetreatmentarea.Bymonitoringtreatmentresponse,RCMmayhelptoadjust
treatmentfrequencyandduration,therebymaximizingtherapeuticoutcomeandpotentiallyreducingtreatment
relatedexpenses.
Insummary,RCMrepresentsapromisingopticaltechniqueinclinicalandinvestigationaldermatologyandmay
haveasignificantimpactonthediagnosisandmanagementofmelanomaandNMSCinthefuture.However,
furtherinvestigationsareneededtobetterassessthevaluesofthepreviousfindings.
ExpertCommentary
Thecurrentdiagnosticgoldstandardindermatologyisaskinbiopsyandsubsequentroutinehistopathologic
evaluation.Anincreasinginterestinnoninvasivediagnostictechnologieshasbeenobservedinrecentyears.The
12/16
11/4/2015
abilityofimagingtheskinwithoutanyinvasiveprocedureopensupnewperspectivesforbothphysiciansand
patients.WithRCM,cellulardetailsoftheskincanbevisualizedandanalyzed.RCMenablesthevisualizationof
pathologicchangesintheepidermalandupperdermalcompartment,bothinvivoandnoninvasively.RCMmaybe
usedforthedifferentialdiagnosisofinflammatoryandneoplasticskinconditions,includingNMSC.Thepotentialto
guidebiopsyprocedures,monitortherapyanddetectsubclinicallesionsillustratethewiderangeofapplicationsin
clinicalandinvestigationaldermatology.Thus,RCMisapromisingtechniquethatmay,ultimately,impactthe
diagnosticandtherapeuticmanagementofskindisease.However,althoughthetechniqueiseasilylearned,
standardizedtrainingwithregardtoimageinterpretationisimportantandshouldbeperformedsystematicallyin
practicaltrainingcourses.Owingtopresenttechnicallimitations,RCMwillnotreplaceroutinehistopathology,but
ratherrepresentsanadjunctdiagnostictool.Inthatregard,RCMmayhelptoreducethenumberofdiagnostic
biopsies,increasediagnosticaccuracy,evaluatethelateraltumormarginsandassesstherapeuticefficacy.
FiveyearView
Todate,RCMisusedmainlyinuniversityandresearchsettings.However,owingtotheimmensepotentialofthe
technique,itwillmostlikelyfinditswayintodailyclinicalpracticeofhospitalandofficebaseddermatologists.RCM
maybeusedforthedifferentialofNMSC(e.g.,BCCandAK)andpigmentedlesions(e.g.,nevi,melanomaand
pigmentedBCC),yetthetechniquehasatremendouspotentialfortheevaluationofotherinflammatoryand
proliferativeskinconditions.Thefurtherdevelopmentofthetechniquewillinclude3Dimagesoftheskin,which
mayimprovediagnosisandoffersnewinsightintocutaneouspathology.RCMmayalsobeappliedina
teledermatologysetting,wherebyimagesmaybeevaluatedbyexpertsinthefield,whichmaybeofgreatbenefitin
difficultorrarecases.Futuredevelopmentsmayincludethedevelopmentofskindirecteddyesorantibodies,
therebyenhancingRCMimaginganddiagnosticaccuracy.
Sidebar:KeyIssues
Nonmelanomaskincancer(NMSC)representsthemostcommoncancerinhumans.
Reflectanceconfocalmicroscopy(RCM)isanoninvasivediagnostictechniquethatoffersimagingoftheskin
withcellularresolution.
DiagnosisanddifferentialofpathologicskinchangescanbeobtainedbyRCM.
HighsensitivityandspecificityrateshavebeenreportedforthediagnosisofNMSC.
RCMallowsfortheevaluationofskinlesionsovertime(monitoringoftreatmentresponseandefficacy).
Inthefuture,RCMmayhelptoreducethenumberofdiagnosticbiopsies.
References
1. BathHextallF,LeonardiBeeJ,SmithC,MealA,HubbardR.Trendsinincidenceofskinbasalcell
carcinoma.AdditionalevidencefromaUKprimarycaredatabasestudy.Int.J.Cancer121(9),21052108
(2007).
2. MarksR,GebauerK,ShumackSetal.Imiquimod5%creaminthetreatmentofsuperficialbasalcell
carcinoma:resultsforamulitcenter6weekdoseresponsetrial.J.Am.Acad.Dermatol.44,807813(2001).
3. GeisseJK,RichP,PandyaAetal.Imiquimod5%creamforthetreatmentofsuperficialbasalcell
carcinoma:adoubleblind,randomized,vehiclecontrolledstudy.J.Am.Acad.Dermatol.47,390398
(2002).
13/16
11/4/2015
4. MortonCA,MacKieRM,WhitehurstC,MooreJV,McCollJH.Photodynamictherapyforbasalcell
carcinoma:effectoftumorthicknessanddurationofphotosensitizerapplicationonresponse.Arch.
Dermatol.134,248249(1998).
5. CockerellCJ.Histopathologyofincipientintraepidermalsquamouscellcarcinoma("actinickeratosis").J.
Am.Acad.Dermatol.42(1Pt2),1117(2000).
6. FuW,CockerellCJ.Theactinic(solar)keratosis:a21stcenturyperspective.Arch.Dermatol.139,6670
(2003).
7. RwertHuberJ,PatelMJ,ForschnerTetal.Actinickeratosisisanearlyinsitusquamouscellcarcinoma:a
proposalforreclassification.Br.J.Dermatol.156(Suppl.3),812(2007).
8. BraakhuisBJ,TaborMP,KummerJA,LeemansCR,BrakenhoffRH.AgeneticexplanationofSlaughters
conceptoffieldcancerization:evidenceandclinicalimplications.CancerRes.63(8),17271730(2003).
9. GreenA,BattistuttaD.IncidenceanddeterminantsofskincancerinahighriskAustralianpopulation.Int.J.
Cancer46,356361(1990).
10. StockflethE,KerlH.GuidelineSubcommitteeoftheEuropeanDermatologyForum.Guidelinesforthe
managementofactinickeratoses.Eur.J.Dermatol.16(6),599606(2006).
11. MogensenM,JemecGB.Diagnosisofnonmelanomaskincancer/keratinocytecarcinoma:areviewof
diagnosticaccuracyofnonmelanomaskincancerdiagnostictestsandtechnologies.Dermatol.Surg.33(10),
11581174(2007).
12. MenziesSW,WesterhoffK,RabinovitzH,KopfAW,McCarthyWH,KatzB.Surfacemicroscopyof
pigmentedbasalcellcarcinoma.Arch.Dermatol.136(8),10121016(2000).
13. PerisK,AltobelliE,FerrariAetal.Interobserveragreementondermoscopicfeaturesofpigmentedbasal
cellcarcinoma.Dermatol.Surg.28(7),643645(2002).
14. ArgenzianoG,ZalaudekI,CoronaRetal.Vascularstructuresinskintumors:adermoscopystudy.Arch.
Dermatol.140(12),14851489(2004).
15. GiacomelJ,ZalaudekI.Dermoscopyofsuperficialbasalcellcarcinoma.Dermatol.Surg.31(12),17101713
(2005).
16. DavisDA,DonahueJP,BostJEetal.Thediagnosticconcordanceofactinickeratosisandsquamouscell
carcinoma.J.Cutan.Pathol.32(8),546551(2005).
17. EricsonMB,UhreJ,StrandebergCetal.Bispectralfluorescenceimagingcombinedwithtextureanalysis
andlineardiscriminationforcorrelationwithhistopathologicextentofbasalcellcarcinoma.J.Biomed.Opt.
10(3),034009(2005).
18. StenquistB,EricsonMB,StrandebergC.Bispectralfluorescenceimagingofaggressivebasalcell
carcinomacombinedwithhistopathologicalmapping:apreliminarystudyindicatingapossibleadjunctto
Mohsmicrographicsurgery.Br.J.Dermatol.154(2),305309(2006).
19. LieberCA,KanterEM,MahadevanJansenA.ComparisonofRamanspectrographthroughputusingtwo
commercialsystems:transmissiveversusreflective.Appl.Spectrosc.62(5),575582(2008).
20. OlmedoJM,WarschawKE,SchmittJM,SwansonDL.Opticalcoherencetomographyforthe
characterizationofbasalcellcarcinomainvivo:apilotstudy.J.Am.Acad.Dermatol.(3),408412(2006).
21. GalletlyNP,McGintyJ,DunsbyCetal.Fluorescencelifetimeimagingdistinguishesbasalcellcarcinoma
fromsurroundinguninvolvedskin.Br.J.Dermatol.159(1),152161(2008).
14/16
11/4/2015
22. LinSJ,JeeSH,KuoCJetal.Discriminationofbasalcellcarcinomafromnormaldermalstromaby
quantitativemultiphotonimaging.Opt.Lett.15,31(18),27562758(2006).
23. NijssenA,MaquelinK,SantosLFetal.Discriminatingbasalcellcarcinomafromperilesionalskinusinghigh
wavenumberRamanspectroscopy.J.Biomed.Opt.12(3),034004(2007).
24. YaroslavskyAN,SalomatinaEV,NeelV,AndersonR,FlotteT.Fluorescencepolarizationoftetracycline
derivativesasatechniqueformappingnonmelanomaskincancers.J.Biomed.Opt.12(1),014005(2007).
25. AstnerS,DietterleS,OtbergN,RwertHuberHJ,StockflethE,LademannJ.Clinicalapplicabilityofinvivo
fluorescenceconfocalmicroscopyfornoninvasivediagnosisandtherapeuticmonitoringofnonmelanomaskin
cancer.J.Biomed.Opt.13(1),014003(2008).
26. RajadhyakshaM,AndersonRR,WebbRH.Videorateconfocalscanninglasermicroscopeforimaging
humantissuesinvivo.Appl.Opt.38,112(1999).
27. RajadhyakshaM,GonzlezS,ZavislanJM,etal.Invivoconfocalscanninglasermicroscopyofhumanskin
II,advancesininstrumentationandcomparisonwithhistology.J.Invest.Dermatol.13,293303(1999).
28. RajadhyakshaM,GrossmanM,EsterowitzD,WebbRH,AndersonRR.Invivoconfocalscanninglaser
microscopyofhumanskin:melaninprovidesstrongcontrast.J.Invest.Dermatol.104(6),946952(1995).
29. HuzairaM,RiusF,RajadhyakshaM,AndersonRR,GonzlezS.Topographicvariationsinnormalskin,as
viewedbyinvivoreflectanceconfocalmicroscopy.J.Invest.Dermatol.116(6),846852(2001).
30. ChungVQ,DwyerPJ,NehalKSetal.UseofexvivoconfocalscanninglasermicroscopyduringMohs
surgeryfornonmelanomaskincancers.Dermatol.Surg.30(12Pt1),14701478(2004).
31. HornM,GergerA,KollerSetal.Theuseofconfocallaserscanningmicroscopyinmicrosurgeryforinvasive
squamouscellcarcinoma.Br.J.Dermatol.156(1),8184(2007).
32. GergerA,HornM,KollerSetal.Confocalexaminationofuntreatedfreshspecimensfrombasalcell
carcinoma:implicationsformicroscopicallyguidedsurgery.Arch.Dermatol.141(10),12691274(2005).
33. PatelYG,NehalKS,ArandaI,LiY,HalpernAC,RajadhyakshaM.Confocalreflectancemosaicingofbasal
cellcarcinomasinMohssurgicalskinexcisions.J.Biomed.Opt.12(3),034027(2007).
34. NoriS,RiusDazF,CuevasJetal.Sensitivityandspecificityofreflectancemodeconfocalmicroscopyfor
invivodiagnosisofbasalcellcarcinoma:amulticenterstudy.J.Am.Acad.Dermatol.51(6),923930(2004).
35. AgeroAL,BusamKJ,BenvenutoAndradeCetal.Reflectanceconfocalmicroscopyofpigmentedbasalcell
carcinoma.J.Am.Acad.Dermatol.54(4),638643(2006).
36. SeguraS,PuigS,CarreraC,PalouJ,MalvehyJ.Dendriticcellsinpigmentedbasalcellcarcinoma:a
relevantfindingbyreflectancemodeconfocalmicroscopy.Arch.Dermatol.143(7),883886(2007).
37. AghassiD,AndersonRR,GonzalezS.Confocallasermicroscopicimagingofactinickeratosesinvivo:a
preliminaryreport.J.Am.Acad.Dermatol.43,4248(2000).
38. UlrichM,MaltuschA,RwertHuberJetal.Actinickeratoses:noninvasivediagnosisforfieldcancerisation.
Br.J.Dermatol.156(Suppl.3),1317(2007).
39. UlrichM,MaltuschA,RiusDiazFetal.Clinicalapplicabilityofinvivoreflectanceconfocalmicroscopyfor
thediagnosisofactinickeratoses.Dermatol.Surg.34(5),610619(2008).
40. HornM,GergerA,AhlgrimmSiessVetal.Discriminationofactinickeratosesfromnormalskinwith
reflectancemodeconfocalmicroscopy.Dermatol.Surg.34(5),620625(2008).
15/16
11/4/2015
41. AstnerS,UlrichM,CuevasJ,GonzlezS.ActinicKeratosis.ReflectanceConfocalofCutaneousTumors.
GonzlezS,HalpernAC,GillM(Eds).InformaHealthcare,London,UK(2007).
42. GoldgeierM,FoxCA,ZavislanJM,HarrisD,GonzalezS.Noninvasiveimaging,treatment,andmicroscopic
confirmationofclearanceofbasalcellcarcinoma.Dermatol.Surg.29(3),205210(2003).
43. TorresA,NiemeyerA,BerkesBetal.5%imiquimodcreamandreflectancemodeconfocalmicroscopyas
adjunctmodalitiestoMohsmicrographicsurgeryfortreatmentofbasalcellcarcinoma.Dermatol.Surg.
30(12Pt1),14621469(2004).
44. ArdigoM,ZieffJ,ScopeAetal.Dermoscopicandreflectanceconfocalmicroscopyfindingsof
trichoepithelioma.Dermatology215,354358(2007).
45. UlrichM,ForschnerT,RwertHuberJetal.Differentiationbetweenactinickeratosesanddisseminated
superficialactinicporokeratoseswithreflectanceconfocalmicroscopy.Br.J.Dermatol.156(Suppl.3),4752
(2007).
ReprintAddress
MartinaUlrich,SkinCancerCenterCharitDepartmentofDermatology,Venerology,andAllergy,Charit
UniversittsmedizinBerlin,Charitplatz1,D10117Berlin,GermanyTel.:+4930450618276Fax:+49304505
18945Email:martina.ulrich@charite.de
ExpertRevDermatol.20083(5):557567.2008ExpertReviewsLtd.
Nowritingassistancewasutilizedintheproductionofthismanuscript.
ThiswebsiteusescookiestodeliveritsservicesasdescribedinourCookiePolicy.Byusingthiswebsite,youagreetothe
useofcookies.
close
16/16

WWW Medscape PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

WWW Medscape PDF

Uploaded by

Copyright:

Available Formats

11/4/2015

You might also like