VivoSight OCT Imaging for Dermatologists

What is Optical Coherence Tomography?

A laser based imaging technique that can image up to 2mm beneath skin. Non-invasive, low intensity, 1310nm laser light. Provides real-time video-rate images without any pre-treatment or gels. Image subsurface skin structure and detect changes in the structure caused by skin care products. 2D and 3D visualization

Technology Comparison

OCT
1 m Smallest resolvable feature 10 m

X-ray / CT
100 m 1 mm

PET
10mm

Ultrasound

MRI

Fingernail image comparison

Multi-Beam OCT

Ultrasound

Images courtesy Guys & St Thomas NHS Trust

OCT presentation of the skin

Disclaimer
The images below result from research undertaken by MDL and our collaborators. We have included for information our preliminary analysis of features within the images relating to the histologically confirmed diagnosis. This initial analysis should be used as guidance only.

Terminology
Areflective: Areas appearing completely black, objects with no internal scattering Hyporeflective/Hyporeflectivity: Areas with scattering that appear dark or darker relative to another layer/structure Hyperreflective/Hyperreflectivity: Areas with scattering that appear bright or brighter relative to another layer/structure

Reflectivity

Areflective Fluid Air

Hyporeflective Proliferating cells Blood Layered keratin Keratinised cells

Hyperreflective Normal cells Collagen Keratin deposits Dense keratin

Composition
Structures and layers appear differently depending on what they are comprised of Main components: Cells Collagen Keratin Fluid

Composition: Cells
Normal epithelial cells Hyperreflective grain texture Due to cell cytoskeleton Proliferating cells Hyporeflective grain texture Due to nucleus size

Dense proliferating cells Dark hyporeflective grain texture Only seen in basal cell carcinoma periphery

Collagen
Dense collagen fibres Hyperreflective mottled texture Hyporeflective areas due to fluid spaces Seen in the reticular dermis Dense aligned collagen fibres Hyperreflective slight mottled texture Seen mainly in scar tissue

Composition: Keratin
Deposits of loose keratin Hyperreflective appearance Undefined borders Layered keratin deposition Mainly hyporeflective Seen mainly on the surface of SCCs Densely packed keratin Hyperreflective upper region getting more hyporeflective with depth

Composition: Fluid
Water/Tissue fluid Areflective or dark hyporeflective Due to edema or intradermal injection Blood filled spaces Hyporeflective Blood flow can be seen Fluid filled space with cell debris Hyporeflective fluid spaces with hyperreflective cell debris

Composition: Fluid: Blood: Blood Flow

Optical Effects
Various non-structural optical effects may cause changes in how structures/layers within the skin appear. Optical effects: Shadowing Surface Reflection Degradation of Signal

Optical Effects: Shadowing

Shadowing is a result of the signal being absorbed or blocked by a structure obscuring all layers/structures below it Vertical areflective band cast by the structure Dense keratin mainly causes this e.g. hair and keratin cysts

Optical Effects: Surface Reflection

Initial bright hyperreflective band on skin surface Not structural Caused by the large change of refractive index between air and skin.

Optical Effects: Degradation of Signal

Progressive loss of signal through a structure or layer Can cause a structure made of a single component, i.e. keratin, to exhibit hyperreflectivity at the surface and increasing hyporeflectivity as depth increases Occurs in all scans causing lower reticular dermis to always appear darker

Layers
Layers of the skin have different characteristics as a consequence of their composition Skin Layers: Epidermis Dermal-Epidermal Junction/Basal Membrane Papillary Dermis Reticular Dermis

Layers
A B C D

C D

A: Epidermis B: Dermal-Epidermal Junction C: Papillary Dermis D: Reticular Dermis

Layers: Epidermis

Top layer of follicular skin below the initial bright surface reflection General hyporeflective appearance Heterogeneous fine granular texture due to being comprised mainly of cells, both epithelial and keratinised A thin dark hyporeflective Stratum Corneum layer can sometimes be observed directly below the surface reflection

Layers: Epidermis

Always a distinct textural difference between epidermis and dermis Grain patterned epidermis and mottled dermis Contrast between layers decreases with age and sun damage

Layers: Dermal-Epidermal Junction

Lowest part of the epidermis bordering with the papillary dermis layer Dark hyporeflective line at the change of contrast between the hyporeflective epidermis and hyperreflective papillary dermis The DEJ involves the basal membrane/ Stratum Basale which is a proliferating cell layer and so appears hyporeflective

Layers: Dermal-Epidermal Junction

The dark hyporeflective line may not always be apparent DEJ is the interface of the epidermis and papillary dermis so is identified mainly by the change in contrast between the two layers

Layers: Papillary Dermis

Superficial layer of the dermis interfacing with the epidermis Hyperreflective appearance due to collagen and cellular components Hyperreflective cell component main contributor in appearance Mottled texture with horizontal patterning due to hyporeflective vasculature and hyperreflective collagen fibre aggregations

Layers: Papillary Dermis

Can be thinner or entirely absent in some cases Usually thinner in more aged skin Can be completely absent in cases of sun damage

Layers: Reticular Dermis

Lowest visible layer of the skin Hyporeflective appearance due to dense collagen and frequency of vessel structures Mottled texture with horizontal disposition due to hyperreflective collagen bundle aggregations with areas of tissue fluid and vessel structures

Features: Vessels

Hyporeflective tube structures with tapering ends Internal scatter pattern caused by blood flow Observed in papillary and reticular dermis layers Size and thickness can vary with person, age and lesion type

Features: Hair Follicles

Appear as a hyporeflective structure spanning the dermal layers and connecting to the epidermis Mostly seen at an incline to the skin surface Evidence of hyperreflective hair protrusion at skin surface

Features: Hair Follicles

Hyporeflective hair follicle structures within the dermis can have areas of hyperreflectivity within indicating the hair shaft within the hyporeflective hair matrix

Features: Hair Follicles: Hair

Hairs within and external to the skin appear hyperreflective due to their keratin content Hairs external to the skin cast shadows on lower layers caused by the dense keratin

Features: Sebaceous Glands

Hyporeflective structure with hazy texture and indistinct more hyporeflective border caused by the keratinised cell boundary Internal scatter caused by hyperreflective cell aggregations with hyporeflective fluid filled secretary spaces Observed in the reticular dermis associated with hair follicles

Features: Traumatised Skin

Loss of layers mainly the papillary dermis Reduced contrast between epidermis and dermis Loss of distinct hyperreflective mottled patterning due to collagen fibre damage Dermal hyporeflectivity due to edema/erythema Areas of localised fluid, edema, pockets

Features: Sun Damaged Skin

Epidermis visible Loss of layers mainly papillary dermis Dermal pattern change due to collagen breakdown (solar elastosis) Reduction/loss of vasculature Hyporeflectivity of dermis due to erythema and increase in fluid content

Features: Scar Tissue

Single homogeneous dermis with distinct epidermis Hyperreflective dermis region due to only collagen being the main component Fine vasculature may be present Absence of hair follicles and associated structures

Features: Cyst: Keratinized

Observed in various sizes in the superficial dermis Hyperreflective surface to the structure and shadow casting due to densely packed keratin Hyporeflective core due to degradation of signal strength Disruptive to surrounding layers

Lesions
Skin lesions present with their own morphological characteristics and often in conjunction with other features: inflammation, sun damage, etc. Skin Lesions: Basal Cell Carcinoma Squamous Cell Carcinoma Seborrheic Keratoses Nevi Scleroderma

Lesions: Basal Cell Carcinoma

Basal Cell Carcinoma (BCC) subtypes: Superficial Nodular Multi-Nodular Characteristic features: Ovoid shape Peripheral boundary DEJ alteration Secondary features include absence of normal features: hair follicles and glands. Vasculature often seen directed towards the basaloid nests.

Lesions: Basal Cell Carcinoma

D A
B

A B

A: Superficial Basal Cell Nest B: Nodular Basal Cell Nest C: Basal Cell Nest Aggregation/ Multi-Nodular D: Epidermal Ulceration

Lesions: BCC: Features: Ovoid Shape

Basal cell nests typically appear as ovoid structures Hyporeflective due to proliferating cells Can be associated with the epidermis (superficial) Or observed in the dermis (nodular)

Lesions: BCC: Features: Peripheral Boundary

Hyporeflective due to peripheral palisading or densely packed cell proliferation zone Hyporeflectivity of cells due to dense packing of small basaloid cells or cells with high nuclear volumes and low cytoplasm content Size of boundary depends on size and maturity of basal cell nest, most evident on dermis facing side of the nest

Lesions: BCC: Features: DEJ Alteration

Disruption to normal DEJ contours Dermis protruding growth from the basal cell layer DEJ appears more hyporeflective in the area of the basal cell nest due to area of proliferating cells

Lesions: BCC: Subtype: Superficial

Hyporeflective ovoid structure within the epidermis Causes severe changes in DEJ contours Peripheral boundary can be less obvious, though normally more evident on dermis facing boundary

Lesions: BCC: Subtype: Superficial

Hyporeflective ovoid structure in and protruding in part from the epidermis Causes severe changes in DEJ contours Peripheral boundary can be less obvious, though normally more evident on dermis facing boundary

Lesions: BCC: Subtype: Superficial

Hyporeflective ovoid protrusion from the epidermis Dark hyporeflective centre due to necrosis, combination of tissue fluid and cell debris More obvious peripheral boundary on dermis facing

Lesions: BCC: Subtype: Nodular

Hyporeflective ovoid structures in the dermis not associated with the epidermis Peripheral boundary more evident encompassing the basaloid nest Usually have visible signs of directed vasculature

Lesions: BCC: Subtype: Nodular

Large nodules can cause the entirety of the dermis to be absent Larger basaloid nests are prone to central necrosis Necrosis appears as a change in texture in the nest at the center due to hyporeflective fluid spaces with cell debris

Lesions: BCC: Subtype: MultiNodular

Basal cell nodules can aggregate into larger structures Appearance of a large nodule with internal hyperreflective areas due to collagenous connective tissue trapped between hyporeflective basaloid nests Lower border of the aggregation always most hyporeflective due to proliferating cell band

Lesions: Squamous Cell Carcinoma

Squamous Cell Carcinoma (SCC) subtypes: In Situ Invasive Characteristic features:

DEJ alteration Epidermal thickening Dermal disruption Hyperkeratotic layering

Secondary features involve: loss of features mainly hair follicles and associated glands along with vessel structures, mainly for invasive subtypes

Lesions: Squamous Cell Carcinoma

C
A B

C
B

A: Epidermal Thickening B: DEJ Alteration C: Hyperkeratotic Layering

Lesions: SCC: Features: DEJ Alteration

Disruption to DEJ contour pattern Hyporeflectivity can occur at border with dermis indicating proliferative area

Lesions: SCC: Features: Epidermal Thickening

Increased thickness of epidermis due to squamous cell proliferation Can appear more hyporeflective at the DEJ due to area of proliferation Heterogeneous epidermal thickening area contains bother hyporeflective proliferating cells and hyperreflective intra and extracellular keratin deposits

Lesions: SCC: Features: Dermal Disruption

Loss of contrast between epidermis and dermis Loss of defined DEJ and layer distinction between epidermis and dermis Hyporeflective epidermis invasion into reticular dermis

Lesions: SCC: Features: Hyperkeratotic Layering

Superficial keratin layers on skin surface Hyperreflective surface reflection with hyporeflective lower keratin layers Denser deposits in the layers cause shadowing effects Lower hyperreflective surface reflection at the start of skin surface

Lesions: SCC: Subtype: In Situ

Only an epidermal component Heterogeneous texture epidermal thickening May have varying amounts of hyperkeratotic layering Protrusion into the dermis but no invasion Distinct divide between epidermis and dermis DEJ can appear altered in contour and more hyporeflective

Lesions: SCC: Subtype: In Situ

Regions of epidermal thickening often appear more hyporeflective varying due to proportions of proliferating cells and cells with intracellular keratin deposits Normal structures and layers can usually be observed under the area Papillary dermis may be thinner or absent

Lesions: SCC: Subtype: Invasive

Epidermal thickening Loss of distinct divide between epidermis and dermis where invasion has occurred Loss of normal layers and features at site of invasion Epidermal invasion appears as a hyporeflective protrusion with undefined boundaries

Lesions: SCC: Subtype: Invasive

Hyperkeratotic can vary in thickness and also be absent in some cases Depth of dermis disruption, epidermal invasion, indicates maturity of lesion Vasculature frequency of appearance and size decreases

Lesions: SCC: Subtype: Invasive

Epidermal invasion can appear as tendril-like protrusions into the dermis Hyporeflective protrusions indicate proliferating neoplastic cells Hyperkeratotic layering absent

Lesions: Seborrheic Keratoses

Characteristic features: Localised Epidermal Thickening Keratin Deposits Epidermal Contour Change

Lesions: Seborrheic Keratosis

Localised epidermal thickening causing bulge in the skin surface Only an epidermal component Keratin deposits can occur in the thickened area in varying sizes and frequency The epidermal bulge contains cells and intra and extracellular keratin deposits

Lesions: Nevi
Nevi subtypes: Junctional Pigmented Junctional Characteristic features: Localised Epidermal Thickening Distinct Rete Protrusions Shadow Effect (Pigmented Only)

Lesions: Nevi: Junctional

Localised epidermal thickening Distinct rete protrusions forming an arch-like pattern across the area Hyporeflective rete ridges indicating blood/fluid perfused spaces

Lesions: Nevi: Junctional

Increased size of hyporeflective rete protrusions Heterogeneous presentation of epidermis Increase in vasculature in the area

Lesions: Nevi: Pigmented Junctional

Prominent increase in rete protrusion size Disruption to the expected DEJ contour Shadowing effect cast from the rete peg apex due to intra and/ or extracellular melanin

Example 1

Hyporeflective structure Associated with epidermis Well defined Peripheral boundary

BCC

Example 2

Localised epidermal thickening Elongated rete pegs

Nevus

Example 3

Layered keratin Loss of layers Epidermal invasion into dermis

SCC

Example 4

Hyporeflective structures Well defined Peripheral boundary

Multiple nodular BCCs

VivoSight
The VivoSight OCT imaging system has been developed with the support of clinicians. It is compliant with European CE mark directives and has FDA 510(k) clearance for use in the USA.

For more information please contact: Daniel Woods Michelson Diagnostics Tel. +44 208 144 9836 Email: enquiries@md-ltd.co.uk
For clinical use in the US FDA 510(k) K093520 applies: VivoSight is a Multi-Beam Optical Coherence Tomography (OCT) system indicated for use in the two-dimensional, cross-sectional, real-time imaging of external tissues of the human body. This indicated use allows imaging of tissue microstructure, including skin, to aid trained and competent clinicians in their assessment of a patient's clinical conditions. US Federal law restricts this device to sale by or on the order of a physician.