Brian P. Hibler

Intraoperative real-time reflectance confocal microscopy for guiding surgical margins of lentigo maligna melanoma.

Lentigo maligna melanoma (LMM) represents a diagnostic and therapeutic challenge because of its heterogeneous nature with poorly defined borders, subclinical extension, and location on sun-damaged skin. Reflectance confocal microscopy (RCM) has advanced the authors’ ability to better diagnose and manage these lesions through noninvasive examination of skin on a cellular level. Herein, the authors report the first case of RCM used intraoperatively, in a multidisciplinary approach involving dermatology and head and neck surgery to manage a challenging LMM. A 77-year-old woman was referred for treatment of an LMM on the left malar cheek approaching the lower eyelid. The lesion had been present for 2 years and previously treated with cryotherapy. On examination, there was an ill-defined 2-cm patch with irregular contour and variegate shades of brown–gray bordering the left lower eyelid (Figure 1). A biopsy revealed spindle cell–type melanoma with a depth of 1.25 mm. Preoperative mapping with RCM identified 2 surrounding areas suspicious for melanoma with epidermal disarray, dendritic hyperreflective melanocytes, and rounded pagetoid cells (Figure 2). Biopsies found invasive melanoma and melanoma in situ. Wide excision in the operating room assisted by RCM with rush pathology and delayed reconstruction was planned. Figure 1 Clinical photograph showing the ill-defined hyperpigmented patch on the left malar cheek approaching the lower eyelid outlined in green. The yellow circles mark areas outside of the clinical lesion where RCM showed suspicious findings, later confirmed ... Figure 2 (A) Reflectance confocal microscopy showing dense areas of hyperreflective, atypical dendritic processes with adnexal tropism. (B) Reflectance confocal microscopy showing pagetoid infiltration within the epidermal layer surrounding the hair follicles. ... Preoperatively, surgical 1 cm margins were defined under Wood lamp. Because of the poorly defined borders, RCM imaging was performed under an institutional review board–approved protocol using a commercially available handheld RCM (VivaScope 3000; Caliber ID, Rochester, NY). The lesion was imaged at the clinical and surgical margins from the stratum corneum down to inside the papillary dermis. Scanning confocal video microscopy was performed to rapidly inspect the border. Reflectance confocal microscopy examination allowed enhanced delineation of the borders and subsequently increased the resection margins. An area around the 9-o’clock margin was suspicious for positivity under RCM because of the presence of sheets of atypical cells and epidermal disarray, but it was not excised for possibility that it was a false positive because it encompassed a separate cosmetic subunit. It was decided to not increase the surgical margin in this area because of the experimental nature of this technology and instead wait for rush permanent hematoxylin and eosin pathology confirmation. Excision of the lesion and margins down to subcutaneous fat was performed. Then, RCM was used to re-evaluate the periphery of the area of resection. The same region of concern, showing dendritic processes and round pagetoid cells around the 9-o’clock position, was highlighted. A video captured intraoperatively was converted into a mosaic by stitching together individual frames to provide a detailed overview of the peripheral margin, highlighting the atypical findings (Figure 3). Figure 3 Representative section from the mosaic created to assess outside of the surgical margin. Area in the blue rectangle represents normal-appearing tissue architecture. The area within the red circle highlights large atypical hyper-reflective cells at the ... Pathology revealed residual invasive and in situ melanoma within the lesion and melanoma in situ extending to the 9-o’clock margin as suspected on confocal microscopy. The patient returned for re-excision along this margin and closure with a cervical facial flap and full-thickness skin graft. No further melanoma was seen on pathology.

Carbon dioxide laser ablation of basal cell carcinoma with visual guidance by reflectance confocal microscopy: a proof-of-principle pilot study

Laser ablation is an alternative, nonsurgical treatment modality for low‐risk basal cell carcinoma (BCC). However, lack of confirmative tumour destruction or residual tumour presence has been a limiting factor to its adoption. Reflectance confocal microscopy (RCM) provides noninvasive, cellular‐level resolution imaging of the skin and is capable of identifying tumour.

Confocal imaging of carbon dioxide laser-ablated basal cell carcinomas: An ex-vivo study on the uptake of contrast agent and ablation parameters.

Laser ablation can be an effective treatment for the minimally invasive removal of superficial and early nodular basal cell carcinomas (BCCs). However, the lack of histological confirmation after ablation results in high variability of recurrence rates and has been a limitation. Reflectance confocal microscopy (RCM) imaging, combined with a contrast agent, may detect the presence (or absence) of residual BCC tumors directly on the patient and thus provide noninvasive histology‐like feedback to guide ablation. The goal of this ex vivo bench‐top study was to determine affective ablation parameters (fluence, number of passes) for a CO2 laser that will allow both removal of BCCs and control of the underlying thermal coagulation zone in post‐ablated tissue to enable uptake of contrast agent and RCM imaging.

Current state of imaging in dermatology.

Medical imaging has dramatically transformed the practice of medicine, especially the field of dermatology. Imaging is used to facilitate the transfer of information between providers, document cutaneous disease, assess response to therapy, and plays a crucial role in monitoring and diagnosing skin cancer. Advancements in imaging technology and overall improved quality of imaging have augmented the utility of photography. We provide an overview of current imaging technologies used in dermatology with a focus on their role in skin cancer diagnosis. Future technologies include three-dimensional, total-body photography, mobile smartphone applications, and computerassisted diagnostic devices. With these advancements, we are better equipped to capture and monitor skin conditions longitudinally and achieve improved diagnostic accuracy of skin cancer.

Handheld Reflectance Confocal Microscopy for the Detection of Recurrent Extramammary Paget Disease

Importance Extramammary Paget disease (EMPD) is commonly refractory to surgical and nonsurgical therapies. Identifying recurrent or persistent EMPD is challenging because the disease is multifocal, and multiple blind scouting biopsies are usually performed in this setting. Handheld reflectance confocal microscopy (HRCM) has been used to diagnose and map primary EMPD and therefore may be used to identify EMPD recurrences. Objective To evaluate HRCM’s diagnostic accuracy in the setting of recurrent or persistent EMPD as well as its potential diagnostic pitfalls. Design, Setting, and Participants This prospective case series study included patients referred to the Dermatology Service at Memorial Sloan Kettering Cancer Center between January 1, 2014, and December 31, 2016, with biopsy-proven EMPD in whom HRCM was used to monitor treatment response. Five patients were included, and 22 sites clinically concerning for recurrent or persistent disease were evaluated using HRCM and histopathologic examination. In 2 patients, video mosaics were created to evaluate large areas. Main Outcomes and Measures Sensitivity and specificity of HRCM in identifying recurrent or persistent EMPD; causes for false-negative results according to their location, histopathologic findings, and previous treatments. Results Of the 22 clinically suspicious sites evaluated in 5 patients (4 men, 1 woman; median [range] age, 70 [56-77] years), 9 (40.9%) were positive for recurrent disease on HRCM and histopathologically confirmed, and 13 (59.1%) sites were negative on HRCM, but 3 of the 13 were positive for EMPD on histopathological examination. In general, HRCM had a sensitivity of 75% and a specificity of 100% in identifying recurrent or persistent EMPD. False-negative results were found in 2 patients and occurred at the margins of EMPD, close to previous biopsy sites. Creating video mosaics (or video mosaicking) seemed to improve the detection of EMPD. Conclusions and Relevance Handheld reflectance confocal microscopy is a useful auxiliary tool for diagnosing EMPD recurrences and can be used to guide scouting biopsies, thus reducing the number of biopsies needed to render a correct diagnosis.

Radiation therapy for synchronous basal cell carcinoma and lentigo maligna of the nose: Response assessment by clinical examination and reflectance confocal microscopy

Radiation therapy (RT) is a noninvasive treatment for a variety of skin cancers. Although surgery is often preferred for basal cell carcinoma (BCC) and lentigo maligna (LM), these conditions often affect patients that are medically inoperable, who decline surgery, or have lesions in challenging anatomic locations. Although nonsurgical treatments can be employed, close monitoring for disease recurrence and progression is of utmost importance. Typically, this is carried out by clinical examination, without adjunctive imaging. Reflectance confocal microscopy (RCM) is an emerging imaging technology that is proving useful to aid in the assessment of treatment response and disease recurrence (Fig 1). RCM has a high

A case of delayed anaphylaxis after laser tattoo removal

It is estimated that nearly a quarter of all persons aged 18 to 50 in the United States have a tattoo.1 Demand for tattoo removal has increased, with an estimated 1 in 5 persons considering tattoo removal.1 American Society for Dermatologic Surgery physicians reported about 100,000 laser tattoo removal procedures in 2013, up more than 50% from 2012.2 Motives for removal include aesthetic reasons, poor tattoo result, and professional or social stigma. Laser-assisted tattoo removal remains the gold standard treatment. With increasing demand for tattoo removal, it is important to be cognizant of adverse events that may occur. We report the novel case of a woman who had an allergic cutaneous reaction at a distant, untreated tattoo site, and subsequently had a delayed anaphylactic reaction after laser tattoo removal.

Lentigo maligna melanoma with a history of cosmetic treatment: Prevalence, surgical outcomes and considerations

Lentigo maligna (LM) is melanoma in situ on sun‐damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes.

Locally Recurrent Lentigo Maligna and Lentigo Maligna Melanoma: Characteristics and Time to Recurrence After Surgery

BACKGROUND Various studies have reported local recurrence (LR) rates after surgical treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM). However, the time to LR of LM/LMM is not currently known, as few studies report time to LR and have long-term follow-up. OBJECTIVE To define time to LR in LM/LMM after surgical treatment, and to describe features of observed LR. MATERIALS AND METHODS Retrospective single-center study of consecutive patients presenting with locally recurrent LM/LMM. RESULTS Six hundred forty-nine cases of LM/LMM were reviewed; 29 (21 LM, and 8 LMM) of 41 locally recurrent cases had original histology reports and were included. The mean time to LR was 57.5 months (range 7–194). For cases presenting as primary LM, LR was also in situ in 14/21 (67%) of cases. Seven of 21 LM recurred as LMM. Of the 8 primary LMM, 3/8 (37.5%) presented with subsequent LMM and all were slightly deeper on re-excision. CONCLUSION The mean time to LR of LM/LMM is at least 57.5 months, underscoring the importance of long-term follow-up. Seven of 21 LM recurred as invasive disease, but the lack of development of LMM from LM in most recurrent cases confirms LM is slowly progressive.

Metastatic cutaneous apocrine carcinoma: Multidisciplinary approach achieving complete response with adjuvant chemoradiation

Cutaneous adnexal tumors are rare and can present a diagnostic and therapeutic dilemma. Distinguishing primary cutaneous tumors from metastatic carcinoma to the skin requires thorough diagnostic evaluation, including imaging, endoscopy, and histologic and molecular pathologic analysis. As with many rare cancers, there is no standard of care management.1 Here we present the diagnostic approach for a primary cutaneous adenocarcinoma of the scalp with lymph node metastasis and subsequent multimodal therapy.