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50 S. Torii
et al.
Coronary thrombosis in ACS with RFC
(a) (b) (c)
(d) (e) (f)
Coronary thrombosis in ACS with IFC
Figure 10. Two pathologically distinct types of acute coronary events. (a–c) ACS with a ruptured
fibrous cap. Imaging of the coronary arteries in a man aged 59 years with anterior ST-segment
elevation myocardial infarction shows a ruptured fibrous cap, a clinical representation of plaque
rupture described in autopsy specimens. The angiogram (panel a) shows a severe mid-LAD lesion
(arrow). The OCT images (panels b and c) show a large thrombus associated with fibrous cap
rupture (arrow in panel c). (d–f) ACS with an intact fibrous cap. Imaging of the coronary arteries
in a woman aged 65 years with anterior non-ST-segment elevation myocardial infarction shows an
intact fibrous cap, a clinical representation of plaque erosion described in autopsy specimens. The
angiogram (panel d) shows narrowing of the proximal LAD (arrow). An OCT image (panel e) shows
white thrombus occurring at a site with mild disease and no signs of ulceration (arrow). In another OCT
frame obtained just proximal to the site with thrombus (panel f), the thrombus is attached to the luminal
vascular surface (indicated by the arrow). Abbreviations: ACS, acute coronary syndrome; LAD, left
anterior descending coronary artery; OCT, optical coherence tomography. Histological image in panel
a reprinted with permission from Nature Publishing Group © Otsuka, F., et al. Clinical classification
of plaque morphology in coronary disease. Nature Reviews Cardiology, 11(7): 379–389 (2014).
Relative to rupture, the OCT diagnosis of plaque erosion is clinically challenging. The current definition is “definitive” plaque erosion or
“probable” plaque erosion
3
(Figure 10). The diagnosis of erosion by OCT,
however, remains controversial and needs further testing and refinement.
Further limitations of OCT include the inability to separate a lipid pool
from a necrotic core and the failure to recognize the presence or absence
of surface endothelium.
Coronary Arteries 51
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Conclusion
Intravascular imaging, particularly employing OCT/OFDI, has provided
unprecedented information about plaque morphology in vivo. Comparison
of the plaque characteristics in autopsy specimens ex vivo and the in vivo
intracoronary imaging data has allowed identification of pathological features of plaque vulnerability that are amenable to clinical imaging; these
types of studies will enhance the adaption of this technology clinically.
Although currently <10% of catheterization laboratories routinely have
adopted this technology, however, researchers will have to show its benefit
in a wide range of patients before it is universally accepted as an important
diagnostic tool.
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vulnerable plaque by optical frequency domain imaging: An ex vivo autopsy study of
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https://doi.org/10.1142/9789813206984_0004
Skin Chapter
4
Bianca Sanabria∗, Attiya Haroon†,
Raheel Zubair
‡
Introduction
, and Babar Rao
∗,†
In vivo microscopy (IVM) techniques are becoming popular for diagnosing
skin disease. This is particularly true for skin cancer diagnosis, which has a
sizeable body of IVM research. Skin cancer diagnosis is commonly based
on clinical examination followed by biopsy and histological evaluation.
Physicians trained in dermoscopy, the use of a low-power magnifier, and
a non-polarized light source may use that technique to enhance diagnostic
accuracy. There are certain characteristicsof skin that make it well suited for
the application of IVM, which can provide clinicianswith more information
than visualinspection alone. Skin is more easily accessiblethan otherorgans
and the non-invasive nature of in vivo microscopy permits evaluation of the
∗
Rutgers Robert Wood Johnson Medical School, Department of Dermatology, Somerset,
NJ, USA.
†
Rao Dermatology, California, USA.
‡
Cosmetic Laser Dermatology and Platinum Dermatology Partners, San Diego, CA, USA.
55
56 B. Sanabria
et al.
Figure 1. Non-invasive diagnostic systems. Caliber ID VivaScope 1500 RCM imaging system (left),
Michelson Diagnostics VivoSight OCT imaging system (right), and SciBase Nevisense EIS system
(below). Images courtesy of instrument vendors.
skin and diagnosis of harmful conditions in cases where patients may be
hesitant to have a biopsy. For patients with numerous suspicious lesions,
it is impractical to perform a large number of biopsies
In vivo microscopy allows real-time diagnosis of skin lesions at the
bedside. In addition to diagnosis, IVM is also used for surgicalmargin mapping and treatment monitoring. Technological advances have decreased the
size of devices, increased imaging speed and resolution, and improved
usability. This chapter will discuss three in vivo microscopy techniques:
optical coherence tomography (OCT), reflectance confocal microscopy
Skin 57
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(RCM), and electrical impedance spectroscopy (EIS). Figure 1 demonstrates examples of each.
Optical Coherence Tomography (OCT)
Optical coherence tomography is an imaging technique developed in the
1980s that has been primarily used in ophthalmology but is now being used
for dermatology as well. In an OCT system, near-infrared light from a diode
laser is split into a reference arm reflected off of a mirror and a sample or
probe arm reflected off of the sample (in this case, skin). When the arms of
light are combined, the interference pattern created provides information
about the optical path length, which is used to build a real-time image.
OCT modalities used include frequency domain OCT (FD-OCT),
dynamic OCT (D-OCT), and high definition OCT (HD-OCT). FD-OCT
has a lateral resolution of 7.5 µm, an axial resolution of 5 µm, a depth of
2 mm, and a 6 × 6mm field of view (FOV). D-OCT allows visualization
of blood vessels, which improves the accuracy of skin cancer diagnosis.
HD-OCT has a superior lateral and axial resolution of 3 um but a reduced
depth of 750µmandanFOVof1.8 × 1.5 mm.
ing modes and can provide vertical images (similar to histology), horizontal
images (similar to dermoscopy and RCM), and 3D images.
FD-OCT improves the accuracy of basal cell carcinoma (BCC),
actinic keratosis (AK), and squamous cell carcinoma (SCC) diagnosis over
clinic and dermoscopic assessment alone and several studies have established criteria for OCT diagnosis. A key feature of basal cell carcinoma on
OCT are homogenous hyporeflective dermal ovoid structures with reflective borders surrounded by hyperreflective stroma. Actinic keratosis and
squamous cell carcinoma on OCT are characterized by a disruption of the
dermal-epidermal junction (DEJ), thickening of the epidermis, and white
streaks in the upper epidermis representing hyperkeratosis.
observers are able to diagnose BCC with a mean sensitivity and specificity
of 90%. The same observers are able to diagnose AK with a mean sensitivity
of 76% and a mean specificity of 68%.
2
There has been less investigation of FD-OCT for the diagnosis of
melanoma, however D-OCT is able to differentiate benign and malignant
1
OCT has multiple imag-
2
Skilled OCT
58 B. Sanabria
et al.
melanocytic lesions based on vascular patterns. Specifically, there are
densely c lustered red dots in a chaotic distribution in melanoma compared
with a more regular distribution in benign nevi. Invasive melanomas will
also have long linear vessels of irregular size with angulated branches.
3
The
improved resolution of HD-OCT over FD-OCT allows the identification of
subtypes of basal cell carcinoma and the evaluation of melanocytic lesions.
However, benign nevi and malignant melanoma have considerable overlapping features on HD-OCT and some melanomas will have no suspicious
4,5
features at all.
While HD-OCT and D-OCT are superior to FD-OCT
for melanocytic lesions, they are not as accurate as reflectance confocal
microscopy.
There are also reports of amelanotic melanoma being misdiagnosed
as BCC on OCT. Therefore, biopsy should always be considered or else a
misdiagnosed and inadequately treated melanoma may progress.
6
After diagnosis, OCT can be used for surgical margin mapping during Mohs micrographic surgery.
7
Lastly, OCT has been used for the monitoring of non-surgical treatments, such as imiquimod and photodynamic
therapy.
8
Reflectance Confocal Microscopy (RCM)
Reflectance confocal microscopy is an imaging technique that was first
patented in the 1950s, had FDA-approved devices reach the market in the
1990s, and received current procedural terminology (CPT) reimbursement
codes from the US Centers for Medicare and Medicaid Services in 2016.
RCM has the most evidence for its clinical use among IVM technologies,
but while it is used in private offices in Europe, at the current time in the
United States, it is mostly limited to academic centers. This is likely to
change, however, as the popularity of RCM increases.
Reflectance confocal microscopes use a 35 mW 830 nm (infrared)
laser to illuminate tissue. The reflected light passes through a pinhole, which
allows only light from a single plane to reach the detector. The result is a
two-dimensional grayscale, horizontal (en face) image. These microscopes
have a horizontal resolution of 1µm and a vertical resolution of 4 µm.
9
Skin 59
https://avxhm.se/blogs/hill0
This resolution is greater than OCT, allowing the visualization of nuclei
and the identification of dysplastic cells. Contrast is a product of the varying refractive indices of microscopic structures, with melanin, collagen,and
keratin all producing a bright signal on RCM. A stack of 0.5 × 0.5mm
images can be taken at different depths or the images in a single plane
can be stitched together to form an 8 × 8mm
2
mosaic. RCM permits the
visualization of a lesion in its entirety. In contrast, histological examination of a small biopsy may reveal only 1% of a lesion. The depth of RCM
examination is limited to 250 µm, which corresponds to the upper dermis.
RCM is better able to evaluate melanocytic lesions than OCT. In
large studies, a sensitivity of 92–100% and a specificity of 69–92% have
10,11
been reported with experienced RCM interpreters.
Stevenson et al. returned a sensitivity of 93% and a specificity of 76%.
A meta-analysis by
12
A disarranged pattern of keratinocytes, the presence of pagetoid cells in
the epidermis, non-edged papillae and atypical cells at the DEJ, and atypical nests and bright nucleated cells in the dermis are characteristics of
13
melanoma on RCM.
Pellacani, Cesinaro, and Seidenari developed an
algorithm for melanoma diagnosis using two major criteria, which scored
two points each, and four minor criteria, which scored one point each. Major
criteria included atypical melanocytes at the basal layer and non-edged
papillae a t the DEJ. Minor criteria included Pagetoid cells throughout the
lesion, round cells in superficial layers, nucleated cells inside dermal papillae, and cerebriform clusters in the papillary dermis. A score of 3 was the
threshold for melanoma.
13
Similar to OCT, RCM performs well on non-melanocytic tumors.
14
Kadouch et al.
performed a meta-analysis of six studies that found a sensitivity of 97% and a sensitivity of 93% for BCC, though there are a limited
number of studies available. Characteristic confocal features of basal cell
carcinoma include lobulated tumor islands, elongated nuclei oriented along
the same axis (polarization), separation of tumor from surrounding tissue
(clefting), and thick tortuous vessels.
15
Actinic keratoses are characterized on RCM by an irregular pattern
of dysplastic keratinocytes in the epidermis (Figure 4). There may also be
parakeratosis and hyperkeratosis present. These features are also present
in squamous cell carcinoma, in addition to dilated blood vessels, solar
2