| 1. |
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| 2. |
- Börve, Alexander, et al.
(author)
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Smartphone Teledermoscopy Referrals: A Novel Process for Improved Triage of Skin Cancer Patients.
- 2015
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In: Acta dermato-venereologica. - : Medical Journals Sweden AB. - 1651-2057 .- 0001-5555. ; 95:2, s. 186-190
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Journal article (peer-reviewed)abstract
- In this open, controlled, multicentre and prospective observational study, smartphone teledermoscopy referrals were sent from 20 primary healthcare centres to 2 dermatology departments for triage of skin lesions of concern using a smartphone application and a compatible digital dermoscope. The outcome for 816 patients referred via smartphone teledermoscopy was compared with 746 patients referred via the traditional paper-based system. When surgical treatment was required, the waiting time was significantly shorter using teledermoscopy for patients with melanoma, melanoma in situ, squamous cell carcinoma, squamous cell carcinoma in situ and basal cell carcinoma. Triage decisions were also more reliable with teledermoscopy and over 40% of the teledermoscopy patients could potentially have avoided face-to-face visits. Only 4 teledermoscopy referrals (0.4%) had to be excluded due to poor image quality. Smartphone teledermoscopy referrals allow for faster and more efficient management of patients with skin cancer as compared to traditional paper referrals.
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| 3. |
- Dahlén Gyllencreutz, Johan, et al.
(author)
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Diagnostic agreement and interobserver concordance with teledermoscopy referrals
- 2017
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In: Journal of the European Academy of Dermatology and Venereology. - : Wiley. - 0926-9959 .- 1468-3083. ; 31:5, s. 898-903
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Journal article (peer-reviewed)abstract
- BackgroundMalignant melanoma and non-melanoma skin cancers are among the fastest increasing malignancies in many countries. With the help of new tools, such as teledermoscopy referrals between primary health care and dermatology clinics, the management of these patients could be made more efficient. ObjectiveTo evaluate the diagnostic agreement and interobserver concordance achieved when assessing referrals sent through a mobile teledermoscopic referral system as compared to referrals sent via the current paper-based system without images. MethodsThe referral information from 80 teledermoscopy referrals and 77 paper referrals were evaluated by six Swedish dermatologists. They were asked to answer questions about the probable diagnosis, the priority, and a management decision. ResultsTeledermoscopy generally resulted in higher diagnostic agreement, better triaging and more malignant tumours being booked directly to surgery. The largest difference between the referral methods was seen for invasive melanomas. Referrals for benign lesions were significantly more often correctly resent to primary health care with teledermoscopy. However, referrals for cases of melanoma in situ were also incorrectly resent five times. The interobserver concordance was moderate with both methods. ConclusionBy adding clinical and dermoscopic images to referrals, the triage process for both benign and dangerous skin tumours can be improved. With teledermoscopy, patients with melanoma especially can receive treatment more swiftly.
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| 4. |
- Ericson, Marica B, 1974, et al.
(author)
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Fluorescence contrast and threshold limit: implications for photodynamic diagnosis of basal cell carcinoma
- 2003
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In: Journal of Photochemistry and Photobiology. B: Biology. - 1011-1344. ; 69:2, s. 121-7
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Journal article (peer-reviewed)abstract
- This study was designed to evaluate what application time of delta-5-aminolaevulinic acid (ALA) results in highest contrast between tumour and normal skin, in the interval 1-4 h, when using photodynamic diagnosis (PDD) of basal cell carcinomas (BCC) located on the face. Moreover, a value of the demarcation limit has been derived based on the fluorescence variation in normal skin adjacent to the tumour. Forty patients were included in the study, randomly allocated to four different groups with varying ALA application time in the range 1-4 h. The contrast, defined as the ratio between the fluorescence intensity in ALA-treated tumour tissue and normal skin, was calculated for each patient, and the mean values in each group were evaluated as a function of ALA application time. In addition, the fluorescence intensity variation in ALA-treated normal skin adjacent to the tumour was assessed. The results from this study show a peak of the mean contrast values after 3 h ALA application, but due to large interpatient variation, the mean contrast did not differ significantly in the interval 2-4 h. After 2 h ALA application, the fluorescence intensity variation in the normal ALA-treated skin was found to be at a maximum, which suggests that 2 h ALA application is not preferable when using PDD. Based on data of the fluorescence variation in ALA-treated normal skin after 3 and 4 h ALA application, a tolerance interval was calculated implying that values above 1.4 times the mean normal fluorescence indicate an abnormal condition. This tolerance limit agrees well with results obtained in a former study.
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| 5. |
- Ericson, Marica, 1974, et al.
(author)
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Photodynamic therapy of actinic keratosis at varying fluence rates : Assessment of photobleaching, pain and primary clinical outcome
- 2004
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In: British Journal of Dermatology. - : Oxford University Press (OUP). - 0007-0963 .- 1365-2133. ; 151, s. 1204-1212
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Journal article (peer-reviewed)abstract
- Background: Although photodynamic therapy (PDT) is becoming an important treatment method for skin lesions such as actinic keratosis (AK) and superficial basal cell carcinoma, there are still discussions about which fluence rate and light dose are preferable. Recent studies in rodents have shown that a low fluence rate is preferable due to depletion of oxygen at high fluence rates. However, these results have not yet been verified in humans. Objectives: The objective was to investigate the impact of fluence rate and spectral range on primary treatment outcome and bleaching rate in AK using aminolaevulinic acid PDT. In addition, the pain experienced by the patients has been monitored during treatment. Patients/methods Thirty-seven patients (mean age 71 years) with AK located on the head, neck and upper chest were treated with PDT, randomly allocated to four groups: two groups with narrow filter (580-650 nm) and fluence rates of 30 or 45 mW cm-2, and two groups with broad filter (580-690 nm) and fluence rates of 50 or 75 mW cm-2. The total cumulative light dose was 100 J cm-2 in all treatments. Photobleaching was monitored by fluorescence imaging, and pain experienced by the patients was registered by using a visual analogue scale graded from 0 (no pain) to 10 (unbearable pain). The primary treatment outcome was evaluated at a follow-up visit after 7 weeks. Results: Our data showed a significant correlation between fluence rate and initial treatment outcome, where lower fluence rate resulted in favourable treatment response. Moreover, the photo-bleaching dose (1/e) was found to be related to fluence rate, ranging from 4.5 ± 1.0 J cm -2 at 30 mW cm-2, to 7.3 ± 0.7 J cm-2 at 75 mW cm-2, indicating higher oxygen levels in tissue at lower fluence rates. After a cumulative light dose of 40 J cm-2 no further photobleaching took place, implying that higher doses are excessive. No significant difference in pain experienced by the patients during PDT was observed in varying the fluence rate from 30 to 75 mW cm-2. However, the pain was found to be most intense up to a cumulative light dose of 20 J cm-2. Conclusions: Our results imply that the photobleaching rate and primary treatment outcome are dependent on fluence rate, and that a low fluence rate (30 mW cm-2) seems preferable when performing PDT of AK using noncoherent light sources.
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| 6. |
- Halldin, Christina, 1957, et al.
(author)
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Nerve blocks enable adequate pain relief during topical photodynamic therapy of field cancerization on the forehead and scalp
- 2009
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In: British Journal of Dermatology. - 1365-2133. ; 160:4, s. 795-800
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Journal article (peer-reviewed)abstract
- BACKGROUND: Topical photodynamic therapy (PDT) is an effective method when treating extensive areas of sun-damaged skin with multiple actinic keratoses (AKs) (field cancerization) on areas such as the forehead and scalp, and offers excellent cosmetic outcome. The major side-effect of PDT is the pain experienced during treatment. OBJECTIVES: To investigate whether nerve blocks could provide adequate pain relief during PDT of AKs on the forehead and scalp. METHODS: Ten men with symmetrically distributed and extensive AKs on the forehead and scalp were included in the study. Prior to PDT one side of the forehead and scalp was anaesthetized by nerve blocks while the other side served as control. RESULTS: The mean visual analogue scale (VAS) score on the anaesthetized side was 1 compared with 6.4 on the nonanaesthetized side during PDT. This difference was significant (P<0.0001), implying that nerve blocks reduce VAS scores during PDT. CONCLUSIONS: The results of the study support the use of nerve blocks as pain relief during PDT of field cancerization on the forehead and scalp, although individual considerations must be taken into account to find the most adequate pain-relieving method for each patient.
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| 8. |
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| 9. |
- Paoli, John, 1975, et al.
(author)
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Teaching peripheral nerve blocks for the head and neck area to dermatologists.
- 2012
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In: Journal of the European Academy of Dermatology and Venereology : JEADV. - : Wiley. - 1468-3083 .- 0926-9959. ; 26:8, s. 1035-1037
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Journal article (peer-reviewed)abstract
- Background Peripheral nerve blocks in the head and neck region can be useful for a large number of surgical or otherwise painful procedures carried out by dermatologists. As anaesthesiologists cannot always be available to help dermatologists place nerve blocks in outpatient settings, training courses for these physicians are warranted. Objectives To present a method of teaching nerve blocks for the face and scalp to dermatologists during residency and/or continuing medical education programmes. Methods Half-day courses with theoretical education, video demonstrations and supervised 'hands-on' training were organized to teach supraorbital/supratrochlear, infraorbital, mental and occipital nerve blocks. The outcome and effects of these training courses were analysed with a survey amongst participants 1-2years after the course. Results All the 20 participants who responded the survey successfully placed at least one type of nerve block during the course. Thirteen of 20 participants (65%) reported to be able to perform all the nerve block techniques at follow-up. Conclusions Dermatologists can learn how to perform nerve blocks for the face and scalp in a safe and controlled manner through half-day courses, including theory, video demonstrations and supervised 'hands-on' training.
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| 10. |
- Sandberg, Carin, 1969
(author)
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Aspects of Fluorescence diagnostics and photodynamic therapy of non-melanoma skin cancer
- 2009
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Doctoral thesis (other academic/artistic)abstract
- Aspects of fluorescence diagnostics and photodynamic therapy in non-melanoma skin cancer. Carin Sandberg Department of Dermatology and Venereology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ABSTRACT Photodynamic therapy (PDT) is now an established method to treat superficial basal cell carcinoma (BCC), Bowen’s disease (BD) and actinic keratosis (AK). The main advantage of PDT is that it is non-invasive and gives excellent cosmetic results; although the majority of the patients do experience some degree of pain, which can sometimes be extreme. Fluorescence diagnostics (FD) is a method to diagnose mainly BCC, which is the most common type of tumour within the class of non-melanoma skin cancer (NMSC) and accounts for about 80% of all skin tumours. This technique can be used as an in vivo pre-surgical diagnostic tool, which can help to detect occult tumour borders of ill-defined BCCs. In the first study (Paper I), the impact of fluence rate and spectral range on the primary treatment outcome and bleaching rate in AKs using aminolaevulinic acid (ALA)-PDT was studied. Pain during treatment was also registered. The results imply that the photobleaching rate and primary treatment outcome were dependent on the fluence rate and that a low fluence rate (30 mW/cm2) appears preferable. In the second study (Paper II), risk factors related to pain during PDT for AK were investigated. The most important factors relating to the experience of pain seem to be the size and “redness” of the lesion. No significant pain relief with capsaicin was seen. In the third study (Paper III), the transdermal penetration of ALA and methyl-aminolaevulinate (MAL) in vivo were investigated using a microdialysis technique. The results imply that there is no significant difference in transdermal penetration of ALA and MAL in tumour tissue. Detectable levels of the drug were not obtained in almost 50% of the lesions where catheters were inserted 1-1.9 mm into the lesion. Curettage was not found to affect the interstitial concentration, indicating that penetration of the drug might indeed be a problem when treating BCCs thicker than 1 mm. In the final study presented within this thesis (Paper IV), the fluorescence contrast in patients undergoing MAL-PDT for superficial BCCs was evaluated. The MAL fluorescence contrast obtained between the tumour and normal skin was also compared to that obtained in a previous study using ALA. In both cases it was possible to identify areas in the fluorescence images corresponding to a tumour and to surrounding normal skin. The mean fluorescence contrast with MAL, however, was significantly higher than the mean fluorescence contrast after application of ALA. Thus, MAL generally renders a higher tumour contrast compared to ALA in superficial BCCs. No correlation between fluorescence and treatment response could be observed. The results of this thesis prove that PDT, using either ALA or MAL, is effective in the treatment of thin non-melanoma skin cancer and pre-cancer. These results further suggest that lower fluence rate should be considered as a precaution to minimise pain response when treating large and inflammatory lesions, although more study is needed. When performing FD, MAL is the best option and lack of treatment response cannot be connected to fluorescence but maybe due to the fact that the pro-drug does not successfully penetrate into the deeper parts of the tumour. Key words: actinic keratosis, aminolaevulinic acid, fluorescence contrast, methyl-aminolaevulinic acid, microdialysis, non-melanoma skin cancer, pain, photodynamic therapy ISBN 978-91-628-7874-0, http://hdl.handle.net/2077/21192 Gothenburg 2009
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| 11. |
- Sandberg, Carin, 1969, et al.
(author)
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Bioavailability of aminolaevulinic acid and methylaminolaevulinate in basal cell carcinomas: a perfusion study using microdialysis in vivo
- 2008
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In: British Journal of Dermatology. - : Oxford University Press (OUP). - 0007-0963 .- 1365-2133. ; 159:5, s. 1170-1176
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Journal article (peer-reviewed)abstract
- Background Photodynamic therapy is becoming a popular treatment for superficial nonmelanoma precancerous and cancerous lesions, showing excellent cosmetic results. Nevertheless, the reported cure rates vary and the transdermal penetration of drugs has been discussed as a limiting factor, particularly for treatment of nodular basal cell carcinoma (BCC). Objectives To investigate the transdermal penetration of aminolaevulinic acid (ALA) and methylaminolaevulinate (MAL) in BCC in vivo using a microdialysis technique. The different prodrugs were compared and the effect of curettage was studied. Methods Twenty patients with 27 histologically verified BCCs (13 superficial, 14 nodular) were included. All lesions were located at the front of the body (head and face excluded). The first 10 patients included were treated with MAL (13 BCCs), and the following 10 patients with ALA (14 BCCs). A light curettage was performed on every second lesion (curettage, n = 13; noncurettage, n = 14). Microdialysis catheters were inserted into the tumours at tissue depths varying from 0.4 to 1.9 mm. Dialysates were collected at 15-30-min intervals for 4 h and the interstitial concentrations of MAL and ALA were determined using high-performance liquid chromatography. Results No significant difference in interstitial drug concentration was observed between lesions treated with ALA or MAL during the 4-h measurement period. However, for the lesions with deeper catheter locations, i.e. at or below 1 mm (n = 11), drug concentrations above the detection limit were obtained in only six lesions. All but one BCC with superficial catheter location, i.e. < 1 mm (n = 16), exhibited detectable drug concentration (P = 0.026). The interstitial peak concentrations were reached within 90 min in 23 of the 27 BCCs, but were not found to be correlated with the depth of the catheters. No difference was found when comparing superficial and nodular BCCs, and the effect of curettage was found to be negligible. Conclusions The results imply that there is no significant difference in transdermal penetration of ALA and MAL in tumour tissue. Detectable levels of drug were not obtained in almost 50% of the lesions where catheters were situated 1-1.9 mm in the lesion. Curettage was not found to affect the interstitial concentration, indicating that penetration of drug indeed might be a problem when treating BCCs thicker than 1 mm.
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| 12. |
- Sandberg, Carin, 1969, et al.
(author)
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Fluorescence Diagnostics of Basal Cell Carcinomas Comparing Methyl-aminolaevulinate and Aminolaevulinic Acid and Correlation with Visual Clinical Tumour Size.
- 2011
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In: Acta dermato-venereologica. - : Medical Journals Sweden AB. - 0001-5555. ; 91:4, s. 398-403
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Journal article (peer-reviewed)abstract
- Fluorescence diagnostics based on aminolaevulinic acid (ALA) fluorescence has been suggested as an in vivo pre-surgical tool for tumour demarcation. We performed fluorescence diagnostics of 35 basal cell carcinomas (BCCs) undergoing photodynamic therapy (PDT) using methyl-aminolaevulinate (MAL). In addition, a semi-automated thresholding algorithm was implemented to detect the potential tumour region. The mean tumour fluorescence contrast was found to be 1.65±0.06 during the first MAL-PDT session, and increased to 1.84±0.07 at the second treatment (p<0.01). This could imply that disruption of the skin barrier and inflammatory responses after the first session of PDT led to higher accumulation of proto-porphyrin IX during the second session of PDT. The tumour areas detected based on fluorescence in small BCCs (<1 cm2) were in general (n=18/23) larger than the visual clinical tumour size. In addition, the fluorescence contrast using MAL (1.65±0.06) was found to be significantly higher (p<10-4) than the contrast (data from previous study) after application of ALA (1.20±0.06). Thus, MAL generally provides higher tumour contrast than ALA in BCCs, and should be preferred for use in fluore-scence diagnostics. Correlation between fluorescence, lack of treatment response and/or pain was not observed.
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| 13. |
- Sandberg, Carin, 1969, et al.
(author)
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Important factors for pain during photodynamic therapy for actinic keratosis
- 2006
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In: Acta dermato-venereologica. - : Medical Journals Sweden AB. - 1651-2057 .- 0001-5555. ; 86:5, s. 404-8
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Journal article (peer-reviewed)abstract
- Photodynamic therapy (PDT) is an efficient treatment for actinic keratosis. A common problem, however, is pain. The aim of this study was to investigate pain during PDT for actinic keratosis. The possibility of using capsaicin cream for pain relief was also assessed. Pain was investigated during aminolaevulinic acid PDT in 91 patients. Size, redness, scaling and induration of the lesions were recorded. Maximum pain during treatment was registered, using a visual analogue scale (0-10). The pain-reducing efficacy of capsaicin was tested in a pilot study in six patients (10 lesions). These patients were pre-treated with capsaicin cream for one week before commencing PDT. Pain was found to be normally distributed around a mean value of visual analogue scale 4.6. Larger lesions gave more pain (p=0.001). The redness of the actinic lesions was found to be related to PDT-induced pain (p=0.01), the reduction of actinic area (p=0.007), and the cure rate (p=0.01). The redder the actinic area, the better the treatment outcome and the more pain experienced. Patients with the largest reduction in the actinic area experienced more pain (p=0.053). The most important factors for presence of pain seem to be the size and the redness of the lesion. No significant pain relief was experienced after pre-treatment with capsaicin.
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| 14. |
- Strömberg, Ulf, et al.
(author)
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Cutaneous malignant melanoma show geographic and socioeconomic disparities in stage at diagnosis and excess mortality.
- 2016
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In: Acta oncologica (Stockholm, Sweden). - 1651-226X. ; 55:8, s. 993-1000
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Journal article (peer-reviewed)abstract
- Background Preventive measures are needed to counteract the increasing burden of cutaneous malignant melanoma (CMM). As a basis for rational melanoma prevention, we investigated geographic differences and impact from socioeconomic factors related to incidence, clinical stage at diagnosis and outcome. Material and methods All patients with primary invasive CMM diagnosed in 2004-2013 in the southern and the western Swedish health care regions with a population of 2.9 million adults were eligible for the study. Population-based data were obtained from the national Cancer Register and the national Melanoma Quality Register. Geographic and socioeconomic differences in incidence per stage at diagnosis were mapped and correlated to excess mortality. Results Disease mapping based on 9743 cases in 99 municipalities and 20 metropolitan districts showed marked, regional disparities in stage-specific incidence of CMM. The incidence of stage I-II tumors was higher in the western health care region, whereas the incidence of stage III-IV CMMs was higher in the southern region. The divergent incidence patterns per stage at diagnosis were consistent across population strata based on educational level. The geographic disparities in CMM stage influenced relative survival with an excess five-year mortality ratio in the southern region versus the western region of 1.49 (95% confidence interval 1.22-1.82). The excess mortality ratio for patients with low versus high educational level was 1.81 (1.37-2.40). Conclusion Residential region and educational level influenced CMM stage and, thereby, excess mortality. These observations suggest that geographic as well as socioeconomic data should be considered in prevention of CMM.
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| 15. |
- Togsverd-Bo, K., et al.
(author)
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Photodynamic therapy is more effective than imiquimod for actinic keratosis in organ transplant recipients: a randomized intraindividual controlled trial
- 2018
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In: British Journal of Dermatology. - : Oxford University Press (OUP). - 0007-0963 .- 1365-2133. ; 178:4, s. 903-909
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Journal article (peer-reviewed)abstract
- Background Actinic keratoses (AKs) in solid organ transplant recipients (OTRs) are difficult-to-treat premalignancies and comparison of topical therapies is therefore warranted. Objectives In an intraindividual study to compare the efficacy and safety of field treatment with methyl aminolaevulinate photodynamic therapy (MAL-PDT) and imiquimod (IMIQ) for AKs in OTRs. Methods OTRs (n = 35) with 572 AKs (grade I-III) in two similar areas on the face, scalp, dorsal hands or forearms were included. All patients received one MAL-PDT and one IMIQ session (three applications per week for 4 weeks) in each study area according to randomization. Treatments were repeated after 2 months (IMIQ) and 3 months (PDT) in skin with incomplete AK response. Outcome measures were complete lesion response (CR), skin reactions, laboratory results and treatment preference. Results The majority of study areas received two treatment sessions (PDT n = 25 patients; IMIQ n = 29 patients). At 3 months after two treatments, skin treated with PDT achieved a higher rate of CR (AK I-III median 78%; range 50-100) compared with IMIQ-treated skin areas (median 61%, range 33-100; P < 0.001). Fewer emergent AKs were seen in PDT-treated skin vs. IMIQ-treated skin (0.7 vs. 1.5 AKs, P = 0.04). Patients developed more intense inflammatory skin reactions following PDT, which resolved more rapidly compared with IMIQ (median 10 days vs. 18 days, P < 0.01). Patient preference (P = 0.47) and cosmesis (P > 0.30) were similar for PDT and IMIQ. Conclusions Compared with IMIQ, PDT treatment obtained a higher rate of AK clearance at 3-month follow-up and achieved shorter-lasting, but more intense, short-term skin reactions.
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