Image Gallery: Super‐high magnification dermoscopy can identify pigmented cells: correlation with reflectance confocal microscopy

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An Updated Algorithm Integrated With Patient Data for the Differentiation of Atypical Nevi From Early Melanomas: the idScore 2021

Introduction: It is well known that multiple patient-related risk factors contribute to the development of cutaneous melanoma, including demographic, phenotypic and anamnestic factors. Objectives: We aimed to investigate which MM risk factors were relevant to be incorporated in a risk scoring-classifier based clinico-dermoscopic algorithm. Methods: This retrospective study was performed on a monocentric dataset of 374 atypical melanocytic skin lesions sharing equivocal dermoscopic features, excised in the suspicion of malignancy. Dermoscopic standardized images of 258 atypical nevi (aN) and 116 early melanomas (eMM) were collected along with objective lesional data (i.e., maximum diameter, specific body site and body area) and 7 dermoscopic data. All cases were combined with a series of 10 MM risk factors, including demographic (2), phenotypic (5) and anamnestic (3) ones. Results: The proposed iDScore 2021 algorithm is composed by 9 variables (age, skin phototype I/II, personal/familiar history of MM, maximum diameter, location on the lower extremities (thighs/legs/ ankles/back of the feet) and 4 dermoscopic features (irregular dots and globules, irregular streaks, blue gray peppering, blue white veil). The algorithm assigned to each lesion a score from 0 to 18, reached an area under the ROC curve of 92% and, with a score threshold ≥ 6, a sensitivity (SE) of 98.2% and a specificity (SP) of 50.4%, surpassing the experts in SE (+13%) and SP (+9%).Conclusions: An integrated checklist combining multiple anamnestic data with selected relevant dermoscopic features can be useful in the differential diagnosis and management of eMM and aN exhibiting with equivocal features

Line-field confocal optical coherence tomography: a new tool for non-invasive differential diagnosis of pustular skin disorders

Background The spectrum of pustular skin disorders (PSD) is large and particularly challenging, including inflammatory, infectious and amicrobial diseases. Moreover, although pustules represent the unifying clinical feature, they can be absent or not fully developed in the early stage of the disease. The line-field confocal optical coherence tomography (LC-OCT) is a recently developed imaging technique able to perform a non-invasive, in vivo, examination of the epidermis and upper dermis, reaching very high image resolution and virtual histology. Objectives We aimed to investigate the potentialities of LC-OCT in the non-invasive differential diagnosis of a series of 11 PSD with different aetiology, microscopic features, body location and incidence rates. Materials and Methods Complete LC-OCT imaging (i.e. 2D/3D frames, videos) was performed on a total of 19 patients (10 females and 9 males) aged between 35 and 79 years. Images were blindly evaluated and compared with corresponding histopathologic findings. Results The LC-OCT imaging was able to detect with high accuracy the pustule structure including shape, margins, morphology and cellular content, along with peculiar epidermal and adnexal alterations in each condition, including: Acute Generalized Exanthematous Pustulosis, Generalized pustular psoriasis, Generalized pustular figurate erythema, Subcorneal Pustular Dermatosis, Intraepidermal IgA pustulosis, Palmoplantar pustulosis, Palmoplantar pustular psoriasis. Herpetic whitlow, Acrodermatitis continua of Hallopeau, Vesicopustular Sweet syndrome and Vesicopustular Eosinophilic cellulitis, with pustular appearance, were also compared. Conclusions The new LC-OCT can represent a rapid, non-invasive and painless tool which can help differentiating among PSD of different aetiology and microscopic morphology in clinical mimickers in daily practice

UVA-1 phototherapy as adjuvant treatment for eosinophilic fasciitis: in vitro and in vivo functional characterization

Introduction: Eosinophilic fasciitis (EF) is a rare autoimmune disease causing progressive induration of dermal, hypodermal, and muscularis fascia. The exact pathogenesis is yet to be fully understood, and a validated therapy protocol still lacks. We here aimed to realize a clinical–functional characterization of these patients. Materials and methods: A total of eight patients (five males, 45 years average) were treated with adjuvant high-dose UVA-1 phototherapy (90 J/cm), after having received the standard systemic immunosuppressive protocol (oral methylprednisolone switched to methotrexate). Body lesion mapping, Localized Scleroderma Assessment Tool (LoSCAT), Dermatology Life Quality Index (DLQI), High-Resolution Ultrasound (HRUS) (13-17MHz), and ultra HRUS (55–70 MHz) were performed at each examination time taking specific anatomical points. Gene expression analysis at a molecular level and in vitro UVA-1 irradiation was realized on lesional fibroblasts primary cultures. Results: The LoSCAT and the DLQI showed to decrease significantly starting from the last UVA-1 session. A significant reduction in muscularis fascia thickness (−50% on average) was estimated starting from 3 months after the last UVA-1 session and maintained up to 12 months follow-up. Tissues was detected by HRUS. The UVA-1 in vitro irradiation of lesional skin sites cells appeared not to affect their viability. Molecular genes analysis revealed a significant reduction of IL-1ß and of TGF-ß genes after phototherapy, while MMPs 1,2,9 gene expression was enhanced. Comment: These preliminary in vivo and in vitro findings suggest that UVA-1 phototherapy is a safe and useful adjuvant therapy able to elicit anti-inflammatory effects and stimulate tissue matrix digestion and remodeling at lesional sites

THEORETICAL AND EXPERIMENTAL EVALUATION OF THE WINDOWLESS INTERFACE FOR THE TRASCO-ADS PROJECT

TRASCO-ADS is a national funded program in which INFN, ENEA, and Italian industries work on the design of an accelerator driven subcritical system for nuclear waste transmutation. TRASCO is the Italian acronym for Transmutation (TRAsmutazione) of Waste (SCOrie). One of the most critical aspects in the design of an Accelerator Driven System is related to the interface region, which is the part of the beamline located between the accelerator, operating under UHV conditions, and the pressurized reactor vessel, consisting of a contained plenum of Pb-Bi eutectic (LBE). A so-called window could separate these two environments, but thermomechanical considerations and radioprotection issues point out that this component could be critical. In the windowless interface, no window is located between the linac and the spallation target. Only a suitable pumping and trapping system, for the gases and the vapors outcoming from LBE, divides the UHV accelerator and the spallation target vacuum. Vacuum gas dynamics theoretical considerations and calculations are presented in this article. The need for a validation of the theoretical models gave the motivation for an experimental work, whose results are also discussed. Scale-up of the experimental setup to the full system needs accurate analyses for a proper dimensioning of the system in the interface region

Does ergometric stress test induce a procoagulative condition in patients with previous myocardial infarction

A regularly scheduled physical training program seems to have antithrombotic effects. Moreover, the hemostatic changes occurring in patients with coronary artery disease during acute exercise have not been clearly elucidated. Since stress testing is routinely performed in clinical cardiology, it would be helpful to assess whether patients with coronary artery disease are exposed to acute coronary thrombosis during or soon after sustained physical exercise. This study was designed to evaluate the effect of acute physical exercise (stress test by bicycle ergometer) on blood coagulation in a group of patients with previous myocardial infarction, and to determine whether the antithrombotic therapy commonly administered favorably influences hemostatic equilibrium. Our results suggest that exercise testing is not harmful to patients with previous myocardial infarction in regard to hemostasis and fibrinolysis and that antithrombotic therapy reduces postexercise increase in platelets

Comparison of reflectance confocal microscopy and line-field optical coherence tomography for the identification of keratinocyte skin tumours

Background: Reflectance confocal microscopy (RCM) and line-field confocal optical coherence tomography (LC-OCT) are non-invasive imaging devices that can help in the clinical diagnosis of actinic keratosis (AK) and cutaneous squamous cell carcinoma (SCC). No studies are available on the comparison between these two technologies for the identification of the different features of keratinocyte skin tumours. Objectives: To compare RCM and LC-OCT findings in AK and SCC. Methods: A retrospective multicenter study was conducted. Tumours were imaged with RCM and LC-OCT devices before surgery, and the diagnosis was confirmed by histological examinations. LC-OCT and RCM criteria for AK/SCC were identified, and their presence/absence was evaluated in all study lesions. Gwet AC1 concordance index was calculated to compare RCM and LC-OCT. Results: We included 52 patients with 33 AKs and 19 SCCs. Irregular epidermis was visible in most tumours and with a good degree of agreement between RCM and LC-OCT (Gwet's AC1 0.74). Parakeratosis, dyskeratotic keratinocytes and both linear dilated and glomerular vessels were better visible at LC-OCT than RCM (p < 0.001). Erosion/ulceration was identified with both methods in more than half of the cases with a good degree of agreement (Gwet AC1 0.62). Conclusions: Our results suggest that both LC-OCT and hand-held RCM can help clinicians in the identification of AK and SCC, providing an in vivo and non-invasive identification of an irregular epidermis. LC-OCT proved to be more effective in identifying parakeratosis, dyskeratotic keratinocytes and vessels in this series

Non-invasive scoring of cellular atypia in keratinocyte cancers in 3D LC-OCT images using Deep Learning

Diagnosis based on histopathology for skin cancer detection is today's gold standard and relies on the presence or absence of biomarkers and cellular atypia. However it suffers drawbacks: it requires a strong expertise and is time-consuming. Moreover the notion of atypia or dysplasia of the visible cells used for diagnosis is very subjective, with poor inter-rater agreement reported in the literature. Lastly, histology requires a biopsy which is an invasive procedure and only captures a small sample of the lesion, which is insufficient in the context of large fields of cancerization. Here we demonstrate that the notion of cellular atypia can be objectively defined and quantified with a non-invasive in-vivo approach in three dimensions (3D). A Deep Learning (DL) algorithm is trained to segment keratinocyte (KC) nuclei from Line-field Confocal Optical Coherence Tomography (LC-OCT) 3D images. Based on these segmentations, a series of quantitative, reproducible and biologically relevant metrics is derived to describe KC nuclei individually. We show that, using those metrics, simple and more complex definitions of atypia can be derived to discriminate between healthy and pathological skins, achieving Area Under the ROC Curve (AUC) scores superior than 0.965, largely outperforming medical experts on the same task with an AUC of 0.766. All together, our approach and findings open the door to a precise quantitative monitoring of skin lesions and treatments, offering a promising non-invasive tool for clinical studies to demonstrate the effects of a treatment and for clinicians to assess the severity of a lesion and follow the evolution of pre-cancerous lesions over time.© 2022. The Author(s)

Vascular complications of prosthetic inter-vertebral discs

Five consecutive cases of prosthetic inter-vertebral disc displacement with severe vascular complications on revisional surgery are described. The objective of this case report is to warn spinal surgeons that major vascular complications are likely with anterior displacement of inter-vertebral discs. We have not been able to find a previous report on vascular complications associated with anterior displacement of prosthetic inter-vertebral discs. In all five patients the prosthetic disc had eroded into the bifurcation of the inferior vena cava and the left common iliac vein. In three cases the aortic bifurcation was also involved. The fibrosis was so severe that dissecting out the arteries and veins to provide access to the relevant disc proved impossible. Formal division of the left common iliac vein and artery with subsequent repair was our solution. Anterior inter-vertebral disc displacement was associated with severe vascular injury. Preventing anterior disc displacement is essential in disc design. In the event of anterior displacement, disc removal should be planned with a Vascular Surgeon

Amelanotic/hypomelanotic lentigo maligna: Dermoscopic and confocal features predicting diagnosis

Background: Amelanotic/hypomelanotic lentigo maligna and lentigo maligna melanoma (AHLM/LMM) may be very difficult to diagnose at an early stage. Objectives: To quantify the predictive value of dermoscopic and reflectance confocal microscopy (RCM) features for AHLM/LMM. Methods: Dermoscopic and RCM images of histopathologically diagnosed AHLM/LMM, amelanotic/hypomelanotic benign lesions (AHBL), and amelanotic/hypomelanotic basal and squamous cell carcinomas (AHBCC/AHSCC) of the head and neck from consecutive patients were retrospectively collected and blindly evaluated by three observers to assess presence or absence of dermoscopic and RCM criteria. Results: Overall, 224 lesions in 216 patients including LM/LMM (n = 55, 24.6%), AHBL (n = 107, 47.8%) and AHBCC/AHSCC (n = 62, 27.7%) were analysed. Multivariable analysis showed that milky-red areas (OR = 5.46; 95% CI: 1.51–19.75), peripheral light brown structureless areas (OR = 19.10; 4.45–81.96), linear irregular vessels (OR = 5.44; 1.45–20.40), and asymmetric pigmented follicles (OR = 14.45; 2.77–75.44) at dermoscopy, and ≥3 atypical cells in five fields (OR = 10.12; 3.00–34.12) and focal follicular localization of atypical cells at dermo-epidermal junction (DEJ) (OR = 10.48; 1.10–99.81) at RCM were significantly independent diagnostic factors for AHLM/LMM vs. AHBL. In comparison with AHBCC/AHSCC, peripheral light brown structureless area (OR = 7.11; 1.53–32.96), pseudonetwork around hair follicles (OR = 16.69; 2.73–102.07), and annular granular structures (OR = 42.36; 3.51–511.16) at dermoscopy and large dendritic (OR = 6.86; 3.15–38.28) and round pagetoid cells (OR = 26.78; 3.15–227.98) at RCM led to a significantly increased risk of diagnosing AHLM/LMM. Conclusions: Amelanotic/hypomelanotic lentigo maligna and lentigo maligna melanoma may have the same dermoscopic features of AHM on other body sites, such as milky red areas, peripheral light brown structureless areas and linear irregular vessels. These features, asymmetric pigmented follicles and at RCM ≥ 3 atypical cells in five fields and focal follicular extension of atypical cells at DEJ may help in recognizing AHLM/LMM even when LM conventional features (e.g., obliteration of hair follicles under dermoscopy and large pagetoid cells under RCM) are absent or present only in very small areas of the lesion