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March 2022 Issue

Authors identify the key OCT image characteristics and terminology for evidence-based, practical use in BCC management in clinical routine

OCT has been used since 2011 to assist in the management of BCC, especially for assessment of suspicious lesions and for monitoring effects of noninvasive treatments. Now, two new papers further underpin the powerful capabilities of VivoSight for BCC.

In the first article, published in JEADV by Fuchs et al.[1], a group of international OCT user experts agreed on a consensus set of BCC OCT image characteristics and terminology by applying the evidence-based Delphi methodology. This expert consensus provides a robust scaffold for the international standardization of the clinical use of OCT for BCC management. 

Similarly, in the second article, published in ActaDermatoVeneriologica, by Adan et al. [2], the authors rank specific VivoSight morphologic OCT features in order to accurately discriminate between BCC and non-BCC lesions, and to distinguish between BCC subtypes, and verified by histopathology. The authors then propose an algorithm for diagnosis and subtyping of BCC that could enable the use of a one-stop-shop approach (avoiding biopsy) in patients with a lesion clinically suspected for BCC: If the VivoSight OCT scan then strongly indicated non-superficial BCC, then surgical excision could be planned immediately, or alternatively if the OCT scan clearly indicated superficial BCC, then non-invasive treatment could be planned. The authors state that in their study, 44% of 299 patients, biopsy would be obviated by applying their methodology.

See details in the articles here:

OCT is increasingly being used in nail disease research to:

  • reduce number of biopsies
  • assess nail pathology through characteristic morphologic and vascular OCT bio markers
  • measure and quantify therapeutic efficacies in the treatment of several nail disorders
  • and predict long term treatment outcomes based on early OCT imaging indicators.

VivoSight enables micrometer resolution, in-vivo, non-invasive imaging of nails and the surrounding skin. It is able to visualize the nail plate, bed and matrix with associated pathologies, as well as blood flow in the nail bed. OCT easily penetrates diseased nail revealing details of underlying pathology, even when the nail is heavily discolored. OCT has a penetration depth of almost 2 mm and is much more accurate than ultrasound. We comment on a number of recent publications that highlight the capabilities and benefits of utilizing OCT in research and clinical practice.

Markowitz et al.: Early Success Indication of Lengthy Onychomycosis Treatment through OCT Biomarkers [3]. Potential for significant cost savings from high predictive value of OCT imaging biomarkers.

A new study by Orit Markowitz, MD and Cynthia Chan, MD is the first to show data supporting VivoSight OCT Onychomycosis markers as early indicators of the success or failure at two months of a 48 weeks regimen of topical efinaconazole.

The authors recommend OCT at 2 months as early indicators of treatment failure. If transferred to clinical practice, this could greatly reduce the cost of Onychomycosis therapy for millions of patients by indicating the need to change the therapy early instead of continuing with one that isn’t working.

Rajabi-Estarabadi et al.: Optical Coherence Tomography in Nail Research and Diagnosis [4]

Excellent new book chapter on the utiliy of OCT. Expert physicians describe visualization of nail psoriasis, onychomycosis, nail hematoma, glomus tumor, and myxoid cysts.

The authors further point out that OCT effectively complements other imaging modalities when higher resolution of structural and vascular morphology is required.

 

Abignano et al.: Nailfold Microvascular Imaging by Dynamic Optical Coherence Tomography in Systemic Sclerosis (SSc): A Case- Controlled Pilot Study [5]

Through comparison with the standard technique of Nailfold Video Capillaroscopy (NVC), Abignano et al. demonstrate the potential of VivoSight OCT vascular metrics as new objective outcome measures for systemic sclerosis clinical trials and practice.

Nailfold microvasculopathies are included in very early diagnosis of systemic sclerosis. Dynamic OCT (D-OCT) capillaroscopy is able to invivo visualize capillary morphology, the surrounding skin architecture and quantify vascular flow status of capillaries in the nail fold.

In the study, a significant correlation was found between OCT microvascular flow density and NVC scores. Dynamic OCT has the potential to provide a virtual biopsy of the examined skin sample in patients with SSc.

Ortner et al.: Morphometric Optical Imaging of Microporated Nail Tissue: An Investigation of Intermethod Agreement, Reliability, and Technical Limitations [6]

Several techniques, like wide-field microscopy, OCT and RCM (reflectance confocal microscopy) are useful to quantify morphological differences and treatment effects in nails

However intermethod agreement has not been assessed and this study aimed to evaluate and compare aspects of ease of use, measurement speed, nail morphometry, micropore morphometry, repetability and artifact robustness.

Besides OCT demonstrating highest repeatability of all imaging techniques, it also scored highest among the sum of above mentioned aspects.

Ortner et al.: Morphometric Optical Imaging of Microporated Nail Tissue: An Investigation of Intermethod Agreement, Reliability, and Technical Limitations [6]

Several techniques, like wide-field microscopy, OCT and RCM (reflectance confocal microscopy) are useful to quantify morphological differences and treatment effects in nails

However intermethod agreement has not been assessed and this study aimed to evaluate and compare aspects of ease of use, measurement speed, nail morphometry, micropore morphometry, repetability and artifact robustness.

Besides OCT demonstrating highest repeatability of all imaging techniques, it also scored highest among the sum of above mentioned aspects.

Clinical appearance before and 4 weeks after treatment with adalimumab and prednisone

In summary, the unique capabilities of OCT make it an indispensable instrument in modern nail disease research and exploration of clinical utility. VivoSight OCT also is heavily employed in many other areas of dermatologic research. Please contact us for a demonstration.

Given the increased publications on VivoSight OCT imaging features for BCC (see Latest News), we’d like to remind on the availability of the course “OCT in Practice” (see also in our July 2021 Newsletter).

The modular course is aimed at VivoSight newcomers and experienced users alike. Presently, 12 main topics are being covered (overview >> here) focusing on when and how to ideally use OCT. You will learn how to assess the most common skin tumors and pathology based on typical visual criteria and receive helpful tips and explanations on OCT image interpretation (Figs. 1a, b). We also present rare or experimental OCT applications. Finally, test your knowledge in a quiz on OCT images of BCCs!

Fig. 1b: Topics are further augmented in video tutorials.

OCT is included as an advisory method in the European Guidelines for Diagnosis and Treatment of BCC [8]

To assist clinicians in diagnosing and treating patients with BCC, European Dermatology / Oncology Organizations have developed international Guidelines. The 2019 Guidelines, published in the European Journal of Cancer, make a number of clear statements:

  • “Histological diagnosis may not be required in superficial and small nodular BCCs (< 1 cm) in low risk areas, if clearly diagnosed clinically and/or with non-invasive techniques”. Level of Evidence 1. Recommendation level A (‘shall’).
  • “Aided non-invasive diagnosis with dermatoscopy, reflectance confocal microscopy and/or optical coherence tomography can improve the diagnosis accuracy in difficult-to-recognize BCCs”. Level of Evidence 1. Recommendation level B (‘should’).

Taken together, these European Guidelines advise EU physicians that in the case of low-risk, superficial/small nodular BCCs, biopsy is not essential if the non-invasive diagnosis of BCC with OCT is clear, and that OCT further improves diagnostic accuracy over basic clinical examination. 

These Europe-centric guidelines allow physicians an effective, efficient and very economic way to care for their patients.

Efficient way to delineate margins of BCC lesion with “Quadrant Mapping” method

In their research, OCT experts have developed a method of mapping the hidden sub-surface lateral extent of a BCC. At University of California Irvine, principle investigator Christopher Zachary, FRCP, and medical student John Soliman employ the mapping protocol. “It is important to use a marking pen that does not significantly absorb the 1064 nm wavelength,” commented Dr. Zachary. “We use a red marker (DERMarker, Viscot #1445) and we are not seeing any sparking or hot spots on our drawn perimeter.”

Mapping Protocol:

  • Draw the margin around the clinical signs of the lesion, illustrated by a red line. Divide the margin into four quadrants, such as 3, 6, 9 and 12 o’clock positions (Figs. Step 1 – Step 4)
  • The probing beam of the OCT scanner is illustrated by a black line in the white circle, and live OCT images on the monitor depict whether the BCC lesion is visible inside or outside the margin (red line)
  • In the example case, BCC features are recognized outside the red marked area at the 12 o’clock position and the margin is extended accordingly
  • The process is continued until the whole circumference of the margin has been assessed accordingly
  • Mapping a typical small BCC only takes 3 to 4 minutes
Quadrant Mapping Method: Steps 1 - 4

Do you want to experience VivoSight OCT first hand? Scan your own skin, see how easy it is and assess multiple images and metrics displayed immediately on the skin?

Join us at booth #125. Our specialist will be delighted to demonstrate the system, answer your questions and point out how VivoSight could be of benefit to you.

OCT and VivoSight OCT are also covered in many talks at ASLMS 2022. Please filter the program with the search terms “OCT” or “Optical Coherence Tomography” and enjoy the various presentations.

New Brochure about VivoTools, the powerful OCT skin analysis software

To better appreciate the value of VivoTools,  a new comprehensive brochure is available. Page by page, purpose, features and benefits of VivoTools are presented with examples. Contact us at info@vivosight.com to get your copy of the VivoTools  brochure.

New Brochure about VivoTools, the powerful OCT skin analysis software

To better appreciate the value of VivoTools,  a new comprehensive brochure is available. Page by page, purpose, features and benefits of VivoTools are presented with examples. Contact us at info@vivosight.com to get your copy of the VivoTools brochure.

Christine Fuchs Jacobsen, MD, PhD is a dermatologist at Bispebjerk Hospital in Copenhagen, Denmark with an interest in non-invasive skin imaging techniques.

“I just defended my PhD thesis successfully on “Preclinical investigation of acne vulgaris using non-invasive in-vivo imaging techniques”. The new imaging modalities, especially latest generation OCT and RCM, allowed me to do research and clinical work that would hardly have been possible just a few years ago.

I like the excitement of discovering something new, not just in unique images, but also coupled with quantifying objective metrics, i.e. hard data. So our group, under the leadership of Prof. Merete Haedersdal, is at the leading edge of insights and we enjoy presenting our latest findings to peers.

Christine Fuchs Jacobson, MD, PhD

Just to mention two examples: firstly, through our work investigating acne vulgaris (AV), it is apparent that we now have a capability to image and quantify AV structural and vascular morphology. And this extends also to subclinical manifestations. This allowed us to define signs or imaging biomarkers that correlate with pathology status and some physiological processes [9]. We were able to:

  • find high correlation between acne clinical severity and skin imaging features
  • visualize transfollicular delivery of a microparticulate suspension
  • quantify a significant increase in epidermal thickness and vessel morphology changes
  • and identify OCT and RCM subclinical imaging biomarkers that may allow treatment triage.

Another example is the just published international consensus statement on OCT for Basal Cell Carcinoma [1]. This is a major milestone and was especially driven by our group leader Prof. Merete Haedersdal. The need for standardization utilizing OCT for BCC was recognized and Prof. Haedersdal was instrumental in employing the Delphi method to generate expert opinion-based evidence.

A large group of KOLs and experts converged on specific OCT image characteristics and terminology that provide a robust scaffold for the training of staff, standardized reporting of findings and clinical implementation of OCT in dermatology. The generated consensus validates that OCT has arrived and is approved for use in assessing lesions suspicious of BCC.

Non-invasive imaging technologies are profoundly beneficial and the dermatologic community is just at the beginning of the adoption curve. Recall when the telescope or microscope was invented hundreds of years ago and what discoveries followed. I believe it will be similar with OCT.”

References

1. Fuchs, C., Ortner, V., Mogensen, M., Rossi, A., Pellacani, G., Welzel, J., Mosterd, K., Guitera, P., Nayahangan, L., Johnsson, V., Haedersdal, M., Tolsgaard, M. and (2022), 2021 international consensus statement on optical coherence tomography for basal cell carcinoma: image characteristics, terminology and educational needs. J Eur Acad Dermatol Venereol. https://doi.org/10.1111/jdv.17969

2. Adan F, Mosterd K, Kelleners-Smeets NWJ, Nelemans PJ. Diagnostic Value of Optical Coherence Tomography Image Features for Diagnosis of Basal Cell Carcinoma. Acta Derm Venereol. 2021 Nov 30;101(11):adv00607. https://doi.org/10.2340/actadv.v101.421. PMID: 34724068.

3. Markowitz, O., Chan, C., Evaluating Onychomycosis Outcomes Two Months into an 11-month-long Efinaconazole Regimen: The Role of Optical Coherence Tomography; https://jcadonline.com/onychomycosis-outcomes-2-months-efinaconazole/

4. Rajabi-Estarabadi A., Williams N.M., Tosti A. (2021) Optical Coherence Tomography in Nail Research and Diagnosis. In: Baran R.L. (eds) Advances in Nail Disease and Management. Updates in Clinical Dermatology. Springer, Cham. https://doi.org/10.1007/978-3-030-59997-3_16

5. Abignano G, Green L, Eng S, Emery P, Del Galdo F, Nailfold Microvascular Imaging by Dynamic Optical Coherence Tomography in Systemic Sclerosis: A Case-Controlled Pilot Study, Journal of Investigative Dermatology (2021). https://doi.org/10.1016/j.jid.2021.08.436

6. Ortner, V.K., Holmes, J., Haedersdal, M. and Philipsen, P.A. (2021), Morphometric Optical Imaging of Microporated Nail Tissue: An Investigation of Intermethod Agreement, Reliability, and Technical Limitations. Lasers Surg Med, 53: 838-848. https://doi.org/10.1002/lsm.23304

7. Conti A, Ciardo S, Mandel VD, Bigi L, Pellacani G. Speckled variance optical coherence tomography for the assessment of nail involvement in acrodermatitis continua of Hallopeau: A case study. J Int Med Res. 2016;44(1 suppl):119-123. https://doi.org/10.1177%2F0300060515593263

8. Peris K, Fargnoli MC, Garbe C, Kaufmann R, Bastholt L, Seguin NB, Bataille V, Marmol VD, Dummer R, Harwood CA, Hauschild A, H ller C, Haedersdal M, Malvehy J, Middleton MR, Morton CA, Nagore E, Stratigos AJ, Szeimies RM, Tagliaferri L, Trakatelli M, Zalaudek I, Eggermont A, Grob JJ; European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organization for Research and Treatment of Cancer (EORTC). Diagnosis and treatment of basal cell carcinoma: European consensus-based interdisciplinary guidelines. Eur J Cancer. 2019 Sep;118:10-34. doi: https://doi.org/10.1016/j.ejca.2019.06.003. Epub 2019 Jul 6. PMID: 31288208.

9. Fuchs, C., Ortner, V., Hansen, F., Philipsen, P. and Haedersdal, M. (2021), Subclinical effects of adapalene-benzoyl peroxide: a prospective in vivo imaging study on acne micromorphology and transfollicular delivery. J Eur Acad Dermatol Venereol, 35: 1377-1385. https://doi.org/10.1111/jdv.17140