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发表于 2011-7-26 21:50:27
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好像是在说我吧
我们医院没有这种设备，我也没有操作过。但在工作中多次碰到在其他地方使用皮肤CT误诊的情况，将无色素痣、贫血痣、白色糠疹经皮肤CT检查后报告为白癜的，私立医院较多，也有公立医院的，虽然有一叶障目之嫌，但上述情况使我对这个设备在白癜风诊断上的价值有保留。
皮肤的共聚焦显微镜（confocal laser scanning microscopy）的历史很久了，这两年好像才热起来了，开会时听人讲到过皮肤CT，也看过厂家的介绍材料，我们科曾经也有想引进的想法，因为后来多次碰到上面提到的情况，加上我是学传统皮肤病理出身的，皮肤病理最终还需要传统的病理切片才能出病理诊断报告，意义不是特别大，后来就放弃了引进的想法。也查看过相关的资料，这个主要是辅助检查皮肤肿瘤的，比如黑素瘤、基底细胞癌、鳞癌等，可以无创检查肿瘤侵润深度、范围以及良恶性的辅助判断等，优势在于无创，但不能代替传统的皮肤病理检查。用在色素病的辅助检查文献也看过，比如讲白癜风和无色素痣在共聚焦显微镜下区别的，尚处在探讨节段，依靠这个确诊白癜风好像还不够。
白癜风是比较好诊断但治疗困难的皮肤病，肉眼观察+病史基本上就可以确诊，可疑部位辅以伍德灯就是，极个别难以诊断的通过一般时间的观察看其是否扩散也能明确，实在疑难还可以使用传统的免疫病理来确诊，我不了解共聚焦显微镜在BB诊断上的意义，个人觉得共聚焦显微镜的主要作用在于皮肤肿瘤的辅助检查上。
教科书像新版的Bologia皮肤病学提到的白癜风和其它色素减退病的诊断主要还是靠临床表现、病史和伍德灯；Mekee的皮肤病理学与临床的联系、lever的皮肤病理学皆未提到共聚焦显微镜（CLSM）。在PUBMED上能检索到不少文献，主要是肿瘤诊断方面的，色素病的也有，尚没有明确的说法。国内华山医院在新近的Int J Dermatol（2011 Jun）（见下），上有关于无色素痣和白癜风在CSM下的观察文章，有辅助诊断作用，但我尚未看到全文；杭州三院在2010年的Lasers Med Sci上有关于CLSM在白癜风、无色素痣、炎症后色减的观察文章，也没有那么肯定能靠这个确诊的说法。
个人认为CLSM就像伍德灯一样只是一种辅助检查手段，用的好时有辅助效果，单纯靠这个确诊有些勉强，当然我没有使用CLSM的经验，对其看法是个人意见，不一定对。
刘博士若有这方面的经验欢迎提供一下，让我学习一下。
在PUBMED新检索了一下CLSM，连同以前的看过的一些相关文献列一下，我没有搞过CLSM，估计不全，但能看个大概情况，不全的你补充一下。
杭三院的：
Lasers Med Sci. 2010 Jul;25(4):551-8.
In vivo confocal laser scanning microscopy of hypopigmented macules: a preliminary comparison of confocal images in vitiligo, nevus depigmentosus and postinflammatory hypopigmentation. Xiang W, Xu A, Xu J, Bi Z, Shang Y, Ren Q.
Department of Dermatology, Third Hospital of Hangzhou, Hangzhou, 310009,
The use of confocal laser scanning microscopy (CLSM) may be an eligible alternative for confirmation of the diagnosis of hypopigmented macules. Our purpose was to evaluate CLSM features for non-invasive imaging of vitiligo, nevus depigmentosus and postinflammatory hypopigmentation in vivo. A total of 68 patients with a clinical diagnosis of the aforementioned diseases were included in this study. CLSM was performed on lesional and adjacent normal appearing skin for all patients. In the active and stable phases of vitiligo, CLSM dem**trated a complete loss of melanin in lesional skin in 14 of 25 patients (56.0%) and 16 of 20 patients (80.0%), respectively. In 11 of 25 (44.0%) patients, the amount of melanin in lesional skin decreased in the active phase of vitiligo, but it is noteworthy to know that the melanin was distributed homogeneously in the dermal papillary rings. In four of 20 patients (20.0%), the dermal papillary rings disappeared completely, but some refractile granules and dendrites could be seen in the stable phase of vitiligo, which may indicate the start of vitiligo repigmentation. Although, in 20 of 20 patients (100%) with nevus depigmentosus, the dermal papillary rings lost their integrity and the content of melanin decreased obviously, there must have been melanin in the dermal papillary rings during its development in all patients. Simultaneously, the melanin was distributed heterogeneously in the dermal papillary rings. The content of melanin and dermal papillary rings in postinflammatory hypopigmentation probably depend on the depth and site of the inflammation; moreover, melanophages were observed in postinflammatory hypopigmentation but did not exist in vitiligo and nevus depigmentosus. In addition, the content of melanin and dermal papillary rings in adjacent normal appearing skin showed changes in the active phase of vitiligo but showed no changes in any of the patients in the stable phases of vitiligo, nevus depigmentosus and postinflammatory hypopigmentation. Differences based on CLSM in the aforementioned diseases were the content of melanin and its distribution pattern. CLSM may be useful to discriminate vitiligo, postinflammatory hypopigmentation and nevus depigmentosus in a non-invasive fashion.
华山医院的：
Pan ZY, Yan F, Zhang ZH, Zhang QA, Xiang LH, Zheng ZZ. In vivo reflectance confocal microscopy for the differential diagnosis between vitiligo and nevus depigmentosus. Int J Dermatol. 2011 Jun;50(6):740-5
Nevus depigmentosus (ND) is frequently confused with vitiligo. Differential diagnosis can be difficult. In vivo reflectance confocal microscopy (RCM) is a noninvasive technique for real-time en face imaging of the superficial layers of the skin down to the superficial dermis with cellular level resolution close to conventional histopathology. In this study, we tried to use this new technology to study the features of the distribution of pigment cells of these two hypopigmentation disorders and then concluded the differential features.
METHODS:Sixty vitiligo patients and 62 ND patients were enrolled in the study. Three points in each patient (lesional, margin of the lesi** and adjacent non- lesional points) were examined with RCM. The gray value of image was quantified using software, and we calculated the relative gray value.
RESULTS:The RCM image feature was different between vitiligo and ND patients. The differential diagnosis was made based on the following four RCM features: complete absence of pigment cells; the distribution of pigment cells; the margins; and the relative gray value.
CONCLUSION: RCM can be used as an auxiliary diagnostic tool for the differential diagnosis between vitiligo and ND.
Grossman M, Esterowitz D, Webb RH, etal. In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast. J Invest Dermatol. 1995 Jun;104(6):946-52.
Abstract
Confocal scanning laser microscopy of live human skin was performed to investigate the correlation of in vivo cellular and morphologic features to histology, the effect of wavelength on imaging, and the role of melanin as a contrast agent. We built a video-rate confocal scanning laser microscope for in vivo imaging of human skin. Using a 100 x microscope objective, we imaged high-contrast optical "secti**" of normal skin, vitiliginous skin, and a compound nevus. In vivo "confocal histology" correlated well with conventional histology. The maximum imaging depth increased with wavelength: the epidermis was imaged with visible 400-700-nm wavelengths; the superficial papillary dermis and blood cells (erythrocytes and leukocytes) in the deeper capillaries were imaged with the near infrared 800-900-nm wavelengths. For confocal reflectance imaging, melanin provided strong contrast by increased backscattering of light such that the cytoplasm in heavily pigmented cells imaged brightly. In vivo confocal microscopy potentially offers dermatologists a diagnostic tool that is instant and entirely non-invasive compared to conventional histopathology.
Diaconeasa A, Boda D, Neagu M. The role of confocal microscopy in the dermato-oncology practice. J Med Life. 2011 Jan-Mar;4(1):63-74.
Abstract
Reflectance-mode confocal microscopy (RCM) is a new in vivo skin imaging technique. We present our one-year experience in RCM examinati** in skin tumors and the retrospective analysis of patients enrolled in the Dermatological Department of 'N. Paulescu' Institute using the Fotofinder Dermoscope II? for the dermatoscopy analysis and VivaScope 1500? for in vivo RCM. We established the rank of RCM in the complex algorithm of skin cancer diagnose, showing that the presented experience can open new possibilities to implement this automated image analyzing system in the routine practice. Our analyzed cases clearly showed that confocal microscopy, therefore, optical biopsy, could guide the clinician towards an accurate diagnosis before surgical removal. Moreover, we emphasized that the development of this technique increases the potential of future teledermatologic
其它的相关文章:
1. Curiel–Lewandrowski C, Williams CM, Swindells KJ. Frankenthaler RA, Gonzalez S. Use of In Vivo Confocal Microscopy in Malignant Melanoma: an Aid in Diagnosis and Assessment of Surgical and N**urgical Therapeutic Approaches. Arch Dermatol. 2004;140(9):1127–1132.
2. Gerger A, Koller S, Weger W, Richtig E, Kerl H, Samonigg H, Krippl P. Sensitivity and Specificity of Confocal Laser–Scanning Microscopy for In Vivo Diagnosis of Malignant Skin Tumors. Cancer. 2006;107(1):193–200.
3. Rajadhyaksha M, Grossman M, Esterowitz D. In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast. J Invest Dermatol . 1995;104:946–952. 4
4. A Diaconeasa, D Boda,,M Neagu et al. the role of confocal microscopy in the dermato–oncology practice. J Med Life. 2011 February 15; 4(1): 63–74.
5. Pellacani G. Reflectance–Mode Confocal Microscopy of Pigmented Skin Lesi**–Improvement in Melanoma Diagnostic Specificity . J Am Acad Dermatol. 2005;53(6):979–985.
6. Langley RG, Walsh N, Sutherland AE. The diagnosis accuracy of in vivo confocal scanning laser microscopy compared to dermoscopy of benign and malignant melanocytic lesi**: a prospective study . Dermatology . 2007;215:365–372.
7. Ahlgrimm–Siess V. In vivo confocal scanning laser microscopy of common naevi with globular, homogeneous and reticular pattern in dermoscopy . Br J Dermatol. 2008;158:1000–1007.
8. Nori S. Sensitivity and specificity of reflectance–mode confocal microscopy for in vivo diagnosis of basal cell carcinoma: a multicenter study . J Am Acad Dermatol. 2004;51:923–930.
9. Gonzalez S, Tannous Z. Real–time, in vivo confocal reflectance microscopy of basal cell carcinoma . J Am Acad Dermatol. 2002;47:869–874.
10. Horn M, Gerger A, Ahlgrimm–Siess V. Discrimination of actinic keratoses from normal skin with reflectance mode confocal microscopy . Dermatol Surg. 2008;34:620–625.
11. Pellacani G, Guitera P. The impact of in vivo reflectance confocal microscopy for the diagnostic accuracy of melanoma and equivocal melanocytic lesi** . J Invest Dermatol. 2007;127:2759–2765.
12. Ulrich M, Maltusch A, Rowert–Huber J. Actinic keratoses: non–invasive diagnosis for field cancerisation . Br J Dermatol . 2007;156:13–17.
13. Gerger A, Hofman–Wellenhof R, Samonigg H. In vivo confocal laser scanning microscopy in the diagnosis of melanocytic skin tumors . British Journal of Dermatology. 2009
14. Langley RG, Rajadhyaksha M. Confocal scanning laser microscopy of benign and malignant melanocytic skin lesi** in vivo . J Am Acad Dermatol . 2001;45:365–376.
15. Segura S, Puig S, Carrera C. Development of a two-step method for the diagnosis of melanoma by reflectance confocal microscopy . Journal of the American Academy of Dermatology. 2009;61(2)
16. Pan ZY, Yan F, Zhang ZH, Zhang QA, Xiang LH, Zheng ZZ. In vivo reflectance confocal microscopy for the differential diagnosis between vitiligo and nevus depigmentosus. Int J Dermatol. 2011 Jun;50(6):740-5
17、Kang HY, le Duff F, Passeron T, Lacour JP, Ortonne JP, Bahadoran P. A noninvasive technique, reflectance confocal microscopy, for the characterization of melanocyte loss in untreated and treated vitiligo lesi**. J Am Acad Dermatol. 2010 Nov;63(5):e97-100.
18、Reflectance confocal microscopy for pigmentary disorders. Kang HY, Bahadoran P, Ortonne JP. Exp Dermatol. 2010 Mar;19(3):233-9. Epub 2009 Nov 2. Review.
19 Ardigo M, Malizewsky I, Dell'anna ML, Berardesca E, Picardo M. Preliminary evaluation of vitiligo using in vivo reflectance confocal microscopy. J Eur Acad Dermatol Venereol. 2007 Nov;21(10):1344-50.
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