[Decision criteria and patient characteristics for patient-oriented treatment of field cancerization : Standardized algorithm for personalized treatment concepts]. / Entscheidungskriterien und Patientencharakteristika zur patientenorientierten Therapie der Feldkanzerisierung : Ein standardisierter Bewertungsalgorithmus für individuelle Behandlungskonzepte.

BACKGROUND: Actinic keratosis (AK), which frequently affects larger skin areas (field cancerization), is characterized by chronic course. Weighing therapy-specific advantages and disadvantages of field-oriented therapy for individual patients is challenging. OBJECTIVES: The main objective was the development of patient-oriented decision criteria for the pragmatic classification of field-directed AK treatment options in patients with a predisposition for field cancerization (patient types 1-3). MATERIALS AND METHODS: The development of the decision criteria and patient typology was based on a nominal respectively structured multilevel group process. The developed algorithm was then subsequently applied for the systematic evaluation of field-directed AK therapies. RESULTS: Patient-relevant criteria for the treatment decision included (among others): effectiveness, selectivity, safety, duration of therapy, cosmesis, patient preference and comorbidities. With regard to the decision criteria and patient types in which field therapy was the treatment of choice, daylight photodynamic therapy notably met the requirement profile. CONCLUSION: The definition of patient-relevant and therapy-related decision criteria in AK field therapy allows a systematic yet practice-oriented approach to classify specific treatment options and to derive individual treatment decisions.

Optical coherence tomography of basal cell carcinoma: influence of location, subtype, observer variability and image quality on diagnostic performance.

BACKGROUND: We previously described the principal results from an observational, prospective, multicentre, clinical trial of the diagnostic value of optical coherence tomography (OCT) for basal cell carcinoma (BCC) in a clinical setting. In this trial, much additional useful information was gathered that warranted further analysis, presented here. OBJECTIVES: To investigate the influence of candidate diagnostic criteria, OCT image quality, lesion location, and observer confidence and interobserver variability on the diagnostic performance of OCT, and to assess its potential use for diagnosis of BCC subtypes. METHODS: A total of 234 clinically unclear 'pink lesions' were evaluated in three steps: after clinical examination, after adding dermoscopy and after adding OCT. In addition to the diagnoses (including lesion subtype), observers recorded which of 15 diagnostic criteria the OCT image contained, their confidence in the diagnoses, the OCT image quality and the anatomical location of the lesion. RESULTS: Diagnostic performance of OCT did not depend on the lesion's anatomical location. Good OCT image quality was correlated with improved diagnostic performance, but diagnostic performance for lesions with mediocre image quality was still better than by clinical and dermoscopic examination. The main reason for reduced image quality was superficial scales and crusting. Observer confidence in diagnosis was correlated with diagnostic performance. Interobserver diagnostic performance was consistently higher than clinical examination and dermoscopy across all sites. BCC subtype could be determined with moderate accuracy, but further independent image markers are required. CONCLUSION: OCT is useful in the diagnosis of BCC.

[What is new in basal cell carcinoma?] / Was gibt es Neues zum Basalzellkarzinom?

BACKGROUND: Basal cell carcinoma (BCC) is the most common skin cancer in fair-skinned individuals. Although lymph node or visceral metastases are observed in less than 0.5 % of all cases, BCC can have a fatal course due to its highly invasive growth pattern. OBJECTIVES: To provide a comprehensive update on diagnosis, treatment, and prevention of BCC. MATERIALS AND METHODS: We review the current literature and recommendations of the German guidelines on treatment and prevention of skin cancer. The most pertinent developments are summarized in this review article. RESULTS: The use of optical coherence tomography and reflectance confocal microscopy can significantly improve the diagnosis of BCC compared with clinical assessment and dermoscopy alone. Mohs micrographic surgery remains the therapeutic gold standard for tumors in the head and facial area and tumors with high-risk features. The application of imiquimod, 5­fluorouracil, or photodynamic therapy should be restricted to low-risk superficial tumors. Topical inhibitors of the sonic hedgehog (SHH) pathway are currently being evaluated in early clinical trials. In contrast, vismodegib and sonidegib have been approved for the systemic treatment of locally advanced and metastatic BCC with good response rates. The most common adverse events of both agents are muscle cramps, dysgeusia, diffuse alopecia, weight loss, and fatigue. In an Australian phase III trial, oral nicotinamide (vitamin B3) reduced the occurrence of new BCC by 20 % in skin cancer patients. CONCLUSIONS: Targeted therapy with SHH inhibitors has improved the prognosis of locally advanced and metastatic BCC, albeit at the cost of a significant number of adverse events.

Morphologic features of basal cell carcinoma using the en-face mode in frequency domain optical coherence tomography.

BACKGROUND: Optical coherence tomography (OCT) has become a valuable non-invasive tool in the in vivo diagnosis of non-melanoma skin cancer, especially of basal cell carcinoma (BCC). Due to an updated software-supported algorithm, a new en-face mode - similar to the horizontal en-face mode in high-definition OCT and reflectance confocal microscopy - surface-parallel imaging is possible which, in combination with the established slice mode of frequency domain (FD-)OCT, may offer additional information in the diagnosis of BCC. OBJECTIVES: To define characteristic morphologic features of BCC using the new en-face mode in addition to the conventional cross-sectional imaging mode for three-dimensional imaging of BCC in FD-OCT. METHODS: A total of 33 BCC were examined preoperatively by imaging in en-face mode as well as cross-sectional mode in FD-OCT. Characteristic features were evaluated and correlated with histopathology findings. RESULTS: Features established in the cross-sectional imaging mode as well as additional features were present in the en-face mode of FD-OCT: lobulated structures (100%), dark peritumoral rim (75%), bright peritumoral stroma (96%), branching vessels (90%), compressed fibrous bundles between lobulated nests ('star shaped') (78%), and intranodular small bright dots (51%). These features were also evaluated according to the histopathological subtype. In the en-face mode, the lobulated structures with compressed fibrous bundles of the BCC were more distinct than in the slice mode. CONCLUSION: FD-OCT with a new depiction for horizontal and vertical imaging modes offers additional information in the diagnosis of BCC, especially in nodular BCC, and enhances the possibility of the evaluation of morphologic tumour features.

The invisible basal cell carcinoma: how reflectance confocal microscopy improves the diagnostic accuracy of clinically unclear facial macules and papules.

Difficult to diagnose and early non-melanoma skin cancer lesions are frequently seen in daily clinical practice. Besides precancerous lesions such as actinic keratosis, basal cell carcinomas (BCCs) score the highest frequency in skin tumors. While infiltrative and nodular BCCs require a surgical treatment with a significant impact on the patients' quality of life, early and superficial BCCs might benefit from numerous conservative treatments, such as topical immune-modulators or photodynamic therapy. Dermoscopy has shown a high sensitivity and specificity in the diagnosis of early BCCs, and non-invasive imaging techniques like reflectance confocal microscopy (RCM) have proven to be helpful. The aim of our study was to investigate the importance of RCM in the diagnosis of BCCs with indistinct clinical and dermoscopic features. We retrospectively examined 27 histologically proven BCCs in which diagnosis was not possible based on naked eye examination; we separately reviewed clinical, dermoscopic, and confocal microscopy features and evaluated the lesions meeting the common diagnostic criteria for BCCs, and our diagnostic confidence. All lesions were clinically unclear, with no characteristic features suggestive for BCC; dermoscopy showed in most cases unspecific teleangiectasias (74 %) and micro-erosions (52 %). Confocal microscopy revealed in most of the cases the presence of specific criteria: peripheral palisading of the nuclei (89 %), clefting (70 %), stromal reaction (70 %), dark silhouettes (70 %), inflammatory particles (70 %), and tumor islands (67 %). In the absence of significant diagnostic clinical signs and with unclear dermoscopic features, specific confocal patterns were present in most of the lesions and enabled a correct diagnosis. In the absence of significant clinical features of BCC and in the case of uncertain dermoscopy, striking confocal features are detectable and easy to recognize in most cases. Confocal microscopy can therefore be instrumentful in the diagnosis of the so-called invisible BCCs.

Non-invasive diagnosis of sweat gland dysplasia using optical coherence tomography and reflectance confocal microscopy in a family with anhidrotic ectodermal dysplasia (Christ-Siemens-Touraine syndrome).

BACKGROUND: Anhidrotic ectodermal dysplasia (AED) is an inherited syndrome, which originates mainly from genetic alteration of the ectodysplasin A (EDA) gene. It regularly affects the adnexa of the skin which results in a characteristic phenotype of the patients including hypo- or anhidrosis leading to severe disturbances in the regulation of body temperature. OBJECTIVES: To prevent the development of the symptoms in early childhood promising therapeutic approaches are currently under clinical investigation. In this context, timely diagnosis of this genetic syndrome is crucial. The purpose of our study was the investigation of modern non-invasive imaging methods such as optical coherence tomography (OCT) and reflectance confocal microscopy (RCM) in the immediate diagnosis of AED. METHODS: We examined a 3-year-old boy with the suspicion for an AED syndrome and his family members with RCM and OCT to document presence and characteristic features of sweat glands in comparison to non-affected individuals. RESULTS: The patient and the affected brother showed significantly reduced sweat glands in the imaging compared to the controls. The genetic analysis revealed a mutation of the EDA gene for hemizygosity previously associated with AED and the mother was revealed as the conductor of the genetic alteration. CONCLUSIONS: With the help of non-invasive imaging, we were able to detect sweat gland dysplasia in the affected family members without performing a biopsy which led us to the diagnosis of an AED. The application of modern dermatological imaging techniques might serve as valuable supplementary tools in the immediate, non-invasive diagnosis of genetic syndromes especially in newborns when early therapeutic approaches are planned.

[Optical coherence tomography]. / Optische Kohärenztomographie.

Optical coherence tomography (OCT) was introduced in the 1990s in dermatology and is nowadays established as a noninvasive high-resolution technique for the in vivo evaluation of the skin. To date several studies have been successfully demonstrated the application of OCT for various dermatological questions. The main indication for OCT in the daily practice is the noninvasive diagnosis of nonmelanoma skin cancer such as actinic keratosis and basal cell carcinoma. OCT has also been shown to be a valuable tool in treatment monitoring and evaluation of therapeutic success of noninvasive treatment strategies like topical immune modulators or photodynamic treatment. Other potential applications for OCT include inflammatory diseases, microbial or parasitic infestations of the skin, e.g. scabies mites or onychomycosis. In recent years high-definition OCT devices have been developed that can potentially be used for the evaluation of melanocytic lesions and, due to the higher resolution, for the visualization of intrafollicular demodex mites. Furthermore different commercially available devices offer-in addition to the cross-sectional images-a fast-generated horizontal (en face) imaging mode. With respect to resolution and penetration depth the OCT technique is taking a middle position in comparison to other noninvasive imaging devices in dermatology such as sonography and reflectance confocal microscopy.