Optical coherence tomography for presurgical delineation of basal cell carcinomas on the face-A comparison with histopathology.

BACKGROUND: To minimize the risk of incomplete excision of basal cell carcinomas (BCC) the macroscopic tumor margins should be adequately defined. Optical coherence tomography (OCT) is a non-invasive imaging tool that can provide structural and vascular information about skin cancer lesions. The study objective was to compare the presurgical delineation of facial BCC by clinical examination, histopathology, and OCT imaging in tumors undergoing full excision. METHODS: Ten patients with BCC lesions on the face were examined clinically, with OCT and histopathology at 3-mm intervals, from the clinical lesion border and beyond the resection line. The OCT scans were evaluated blinded and a delineation estimate of each BCC lesion was made. The results were compared to the clinical and histopathologic results. RESULTS: OCT evaluations and histopathology were in agreement in 86.6% of the collected data points. In three cases the OCT scans estimated a reduction of the tumor size compared to the clinical tumor border set by the surgeon. CONCLUSION: The results of this study support the notion that OCT can have a role in the clinical daily practice by aiding clinicians in delineating BCC lesions before surgery.

One-day or two-day procedure for sentinel node biopsy in melanoma?

PURPOSE: We compared the outcome of a 1-day and a 2-day sentinel node (SN) biopsy procedure, evaluated in terms of lymphoscintigraphic, surgical and pathological findings. METHODS: We studied 476 patients with melanoma from two melanoma centres using static scintigraphy and blue dye. A proportional odds model was used for statistical analysis. RESULTS: The number of SNs visualized at scintigraphy increased significantly with time from injection to scintigraphy and activity left in the patient at scintigraphy, and depended on the melanoma location. The number of SNs removed at surgery increased with the number of SNs visualized at scintigraphy and time from injection to surgery. The frequency of nodal metastasis increased with increasing thickness and Clark level of the melanoma, and was highest for two SNs visualized at scintigraphy. CONCLUSION: This study showed that early vs. late imaging and surgery do make a difference on the outcome of the SN procedure and confirmed the importance of the scintigraphic visualization of all true SNs.

UV induced erythema evaluated 24 h post-exposure by skin reflectance and laser Doppler flowmetry is identical in healthy persons and patients with cutaneous malignant melanoma and basal cell cancer.

Twenty-one patients with invasive cutaneous malignant melanoma and 19 patients with basal cell skin cancer and 29 healthy volunteers were phototested on non-UV exposed buttock skin to examine their 24 h reaction to a series of increasing doses of simulated sunlight with 25% dose increments. Skin pigmentation at the phototest sites was determined by skin reflectance before testing to assure an equal level of constitutive skin pigmentation in the 3 groups. Erythema reactions were scored visually 24 hours post-exposure and objective measurements of erythema were performed by skin reflectance and laser Doppler flowmetry. In adjacent non-irradiated skin the redness was also quantified to determine the increase in redness in irradiated skin compared to non-irradiated skin. Constitutional skin pigmentation correlated well to UV sensitivity (r = 0.75) and skin redness measured by skin reflectance technique correlated to laser Doppler flowmetry (r = 0.86). No significant differences in UV doses to barely perceptible erythema or to the higher erythema grades were found between the two skin tumour groups and the control group, and no significant differences were found in skin reflectance measured redness or in laser Doppler flowmetry of any erythema reactions between the 3 groups. The 24 h erythema reaction to sunlight can therefore not be used to distinguish patients with invasive cutaneous malignant melanoma or basal cell carcinoma from normal persons.

Risk of accidental exposure to blood borne infection during plastic surgical operations.

To find out the incidence of accidental exposure to blood borne infections by the operation team in the department of plastic surgery a three month survey was carried out. All episodes of exposure of unprotected skin or mucous membranes to blood were recorded. There were 94 accidents in 746 operations, and 17 (18%) of the injuries penetrated the skin. These were mostly self injuries, typically the surgeon injuring his non-dominant index finger. Only one injured person wanted the patient to have an HIV test after the injury, and none of the injured people wanted an HIV test. Only two reported the injury as an occupational accident.

The metastasizing thin cutaneous melanoma. Case report.

Thin cutaneous melanomas can metastasize and be fatal. We present a case of thin cutaneous malignant melanoma without regression (tumour thickness 0.69 mm) and with metastases to the regional lymph nodes. The literature is reviewed. Patients with thin melanomas should be carefully followed for evidence of metastases irrespective of the actual thickness of the primary tumour.

Observer variation in histological classification of cutaneous malignant melanoma.

To evaluate the variations within and between observers in the interpretation of important histological prognostic factors, a series of 96 melanoma patients was randomly selected from a database of 1691 patients with cutaneous malignant melanoma. The stained sections were examined on two occasions by four experienced pathologists. Analysis by observed agreement and kappa statistics showed maximal tumour thickness to be the best reproducible variable, with ulceration the second best. Regression was the least reproducible, with level of invasion and type of melanoma in the mid range. Intra-observer variation was uniformly less than inter-observer variation for each variable. For tumour thickness a variance component analysis was done to quantify the variability further. The clinician should not base his choice of treatment entirely on the microscopic classification but take into consideration the clinical course and appearance of the tumour.

[Malignant melanoma of the skin in Denmark--epidemiology, diagnosis and treatment]. / Melanoma malignum cutis i Danmark--epidemiologi, diagnostik og behandling.

About 700 new cases of malignant melanoma of the skin are registered annually in Denmark. The incidence is increasing rapidly and the number of new cases increases by more than 5% per annum. The most important phenotypical risk factors are the number of acquired pigmented naevi and exposure to sunlight is the most important risk factor in the external environment so that severe sunburn in children and intermittent intense exposure to sunlight increase the risk of melanoma. The thickness of the tumour at the time of the diagnosis is the most important prognostic factor. The prognosis deteriorates with increasing thickness. Treatment is primarily surgical. In cases of inoperable local melanoma and regional recurrences, irradiation may be administered. Chemotherapy and/or immunotherapy are of experimental character. In the light of the rapidly increasing incidence, it is important that knowledge of risk factors for development of the disease and the clinical characteristics of early melanoma is spread to not only the medical profession but also to the general public.

Pain induced by photodynamic therapy of warts.

BACKGROUND: Photodynamic therapy with topical 5-aminolevulinic acid (ALA), followed by irradiation with red light (ALA-PDT), is used for non-melanoma skin cancer and other dermatological diseases. Pain during and after light exposure is a well-known adverse advent that may be a limiting factor for treatment, particularly, in viral warts. METHODS: To assess the pain induced by ALA-PDT, we asked 45 patients enrolled in a randomized, placebo-controlled trial with six consecutive ALA- and placebo-PDT treatments for recalcitrant foot and hand warts to fill in questionnaires about pain immediately and 24 h after each treatment. RESULTS: Immediately and 24 h after each of the six treatments, pain intensity was significantly higher in warts treated with ALA-PDT than in warts treated with placebo-PDT (P<0.028). Severe or unbearable pain was reported from a median of 17% (6-31%) of the ALA -treated warts and from a median of 2% (0-15%) from the placebo-treated warts immediately after the treatments. With increasing treatments, no significant change in pain intensity was observed and no significant relation was found between the pain intensity and the relative change in wart area. The pain was primarily characterized as burning and shooting. The pain lasted about 30 h (range: 1-96 h). CONCLUSION: We conclude that pain induced by ALA-PDT is of such intensity in about one-fifth of the warts that pain relief is indicated.

Threshold level for measurement of UV sensitivity: reproducibility of phototest.

The ultraviolet (UV) sensitivity is determined by a phototest where the skin is exposed to well-defined doses of UV radiation and the resulting erythema is graded by visual scoring after 20-24 h. In this study we wanted to estimate the reproducibility of erythema assessment in phototesting. Twenty-one healthy Caucasians with skin types I to IV were phototested on UV un-exposed buttock skin using a xenon lamp solar simulator. Twenty-four hours after UV exposure eight physicians independently graded the erythema reactions two times. Data were analysed using inter- and intra-observer agreement and kappa statistics, which adjusts for agreement that could be caused by chance alone. Observed agreement and kappa statistics were found to decrease with increasing intensity of erythema and to be lower for skin types III and IV compared to skin types I and II. Intra-observer agreement was uniformly better than inter-observer agreement. The difference between observers assessment could be as much as three clinical erythema grades. Physicians's previous experience with phototesting only had a minor influence on agreement. In conclusion, phototesting is based on subjective assessment of erythema and is not as precise and reproducible as expected. Agreement was better for barely perceptible erythema than for erythema with a well-defined border and we therefore recommend that the barely perceptible erythema reaction should be used for measurement of the minimal erythema dose.

Seasonal variation of skin pigmentation.

We measured skin pigmentation by skin reflectance monthly from May 1992 to April 1993 in 36 healthy Caucasians. Pigmentation was measured at four UV-exposed sites at the forehead, the upper chest, the inside of the upper arm, and at the upper back. The pigmentation and UV sensitivity were simultaneously measured at UV-protected buttock skin. The results showed a considerable seasonal variation for skin pigmentation at the UV-exposed sites. Buttock skin had a pigmentation and UV sensitivity that varied only marginally. We recommend that measurements of genetically controlled skin pigmentation and constitutive UV sensitivity should be performed at UV-unexposed skin on the buttocks, except in persons that expose this site to artificial or natural sunlight.

Patterns of the first lymph node metastases in patients with cutaneous malignant melanoma of axial localization.

At the Finsen Institute, Copenhagen, from 1971 to 1981, 134 patients were treated for lymph node metastases from primary cutaneous malignant melanoma of axial localization (e.g., in the head and neck and trunk), where metastases to regional lymph node groups were the first sign of dissemination. Due to the lack of sufficient clinical data, 27 patients were excluded from the study. Median time from excision of primary tumor to diagnosis of node metastases was 11 months. In 42 of 85 (49%) patients with truncal melanoma, the primary tumor was placed in the lymphatic water-shed areas. Two patients among this group showed bilateral simultaneous metastases to two different node groups. In the remaining 43 patients with truncal tumors located outside water-shed areas, node metastases developed in unexpected groups in seven (16%) patients. Of 22 patients with head and neck tumors, two (9%) patients demonstrated metastases to distant lymph node groups without metastases to the regional node basins.

Preoperative cutaneous lymphoscintigraphy in malignant melanoma.

To identify the regional lymph node basins cutaneous lymphoscintigraphy with technetium 99m rhenium sulfide colloid (99mTc-ReS) was performed in 45 patients and with technetium 99m antimony sulfide colloid (99mTc-Sb2S3) in seven patients after excisional biopsy of the primary tumor. All patients had skin tumors located in the face or neck or on the trunk with 47 cases of cutaneous malignant melanoma and 5 cases of benign or premalignant lesions. In 48 patients the scintiscans 1 hour after perilesional injection of the tracer colloid clearly showed the lymphatic drainage patterns from the tumor sites, of them 25 patients demonstrated unidirectional drainage, whereas the remaining 23 patients had multidirectional drainage to two or three lymph node groups. There were technical difficulties in performing the examinations in four patients. The authors recommend cutaneous lymphoscintigraphy as a safe, simple and reliable technique for mapping the lymphatic drainage preoperatively in patients with Stage I cutaneous malignant melanoma of axial localization.

Sun-protection behaviour and self-assessed burning tendency among sunbathers.

A total of 805 sunbathing Caucasians were interviewed about sunprotection behaviour and self-assessed burning tendency. Sixty-seven percent of the interviewed sunbathers used one or more sunscreen factors. Sunscreen-users and nonusers were exposed to the sun 206 min and 197 min (P = 0.186), respectively. The sunscreen users were exposed to a marginally higher UV dose than non-sunscreen users, 4.8 SED versus 4.5 SED (P = 0.0348). The rate of sunscreen users was significantly higher among subjects who stated that they always were sunburnt in the spring when not using a sunscreen than subjects who stated that they never were sunburnt in the spring when not using a sunscreen (P = 0.0001). However, when comparing subjects that always burn in the spring and subjects that never burn in the spring, we found no significant difference between level of the sun-protection factor (P = 0.11) nor the duration of sun exposure (P = 0.967), nor to which UV doses the subjects were exposed (P = 0,562). Furthermore we found that the interviewed sunbathers interpreted to "be sunburnt" as more severe than "to turn red". Public campaigns recommend the use of sun protection cream when sunbathing without using other sun protective strategies; however, the use of sun protection cream is inadequate among sunbathers. More education is required to persuade those with more sun-sensitive skin to use a higher protection-factor, to reduce sun exposure at times when UV radiation is most intense, and to reduce the duration of exposure.

Sunscreens used at the beach do not protect against erythema: a new definition of SPF is proposed.

Since sunscreens are recommended by doctors and used all over the world to protect against sun induced erythema, it is important to evaluate if sunscreens are used as recommended and if the intended effect is achieved. We refer to the findings of several studies performed on people at risk of sun-burning at beaches in the vicinity of Copenhagen, Denmark. On a sunny day at the beach 65% of the sunbathers used one or more sunscreens. Of these, 46% used the sunscreen all over the body and a median sun protection factor (SPF) of 5-6 was used. The sunbathers used 0.5 mg/cm2 of sunscreen independent of skin type. Of the sunscreen users, 43% applied the sunscreen after arriving at the beach and 43% reapplied the sunscreen after swimming. The sun exposure time and the sun exposure dose were almost identical among sunscreen users and non-users. Self-assessed redness of the skin demonstrated that more sunscreen users than non-users reported to be red the day after sun exposure, 42 and 34%, respectively. Theoretical calculations support this findings and show a drastic reduction in the achieved photoprotection if a thinner layer than in the test situation is used. Sunscreens do not protect against erythema if not used as intended. Instead of changing people's habits, we suggest modifying the test method by adjusting the amount of sunscreen to that used in real life situations, 0.5 mg/cm2.

Eye and hair colour, skin type and constitutive skin pigmentation as risk factors for basal cell carcinoma and cutaneous malignant melanoma. A Danish case-control study.

To assess the importance of hair and eye colour, skin type and constitutive skin pigmentation as risk factors for basal cell carcinoma and cutaneous malignant melanoma in fair-skinned Caucasians, we conducted two identical case-control studies in Denmark. We studied 145 cases with basal cell carcinoma and 174 matched controls, and 168 cases with cutaneous malignant melanoma and 176 matched controls. Controls were matched on age, gender and place of residence. Subjects indicated their hair colour before 7 years of age, and at 25 years of age and their skin phototype. Interviewers assessed the present hair colour and eye colour, and the constitutive skin pigmentation was measured objectively by skin reflectance of UV unexposed buttock skin. There were no differences between basal cell carcinoma cases and controls in hair colour or eye colour or constitutive skin pigmentation, but more cases were of skin type II than skin type IV; skin type 11 was a risk factor for basal cell carcinoma with an odds ratio (OR) of 2.3. For cutaneous malignant melanoma, more cases than controls were red-haired or blond and of skin type II, but there was no difference in constitutive skin pigmentation. Hair colour and skin type were found to be independent risk factors for cutaneous malignant melanoma; red hair vs. black/brown: OR >9.7, blond hair vs. brown/black: OR = 2.4, and skin type 11 vs. type IV: OR=2.0. There were no gender-related differences in risk factors for basal cell carcinoma and cutaneous malignant melanoma.

Facultative skin pigmentation in caucasians: an objective biological indicator of lifetime exposure to ultraviolet radiation?

To investigate age and gender trends in facultative and constitutive skin pigmentation we measured skin pigmentation non-invasively and objectively by skin reflectance spectroscopy in 653 caucasians (336 females and 317 males; mean age 38 years, range 0-85) who were not using artificial tanning devices. In all subjects, measurements were performed in the late winter and pre-spring period at five sites exposed to ultraviolet (UV) radiation: the forehead, the upper chest, the upper back and the lateral and medial aspects of the upper arm, and in UV-unexposed buttock skin. Constitutive pigmentation at the buttocks was highest in the first years of life and then decreased substantially during the first two decades of life (P < 0.01). After the age of 25 years, buttock pigmentation remained at a constant level (P = 0.20). There was no gender difference in constitutive pigmentation. Facultative skin pigmentation increased with age for all the measured sites with the highest levels found at the lateral aspect of the upper arm. Based on observations in this study we propose the idea of a 'sun exposure index' (SEI) for individuals, based on objective measurements of skin pigmentation. The SEI is calculated as the increase in facultative pigmentation above the constitutive level and is expressed as a percentage of the constitutive level. The SEI appeared to be related to cumulative lifetime UV exposure and may be used in epidemiological research as an objective estimate of UV exposure at different body sites in caucasians.

Skin pigmentation in Caucasian babies is high and evenly distributed throughout the body.

To investigate if Caucasian babies have particular sun sensitive skin and if skin pigmentation before any sun exposure is uniform throughout the body, we measured skin pigmentation objectively by skin reflectance spectroscopy in 10 anatomical sites in 20 healthy Caucasian babies (mean age 5 months, range 1 to 10 months) that had not been sun exposed previously. We found that skin pigmentation at all the measured sites was significantly higher than the constitutive pigmentation in Caucasian adults (P < 0.01). Furthermore, the level of skin pigmentation in all the 10 measured sites in the babies was statistically not different (P < 0.31) and there was no gender differences in pigmentation for any site.