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Editorial |

An Evolving Approach to the Detection of Melanoma and Other Skin Cancers Using In Vivo Reflectance Confocal Microscopy ONLINE FIRST

Alon Scope, MD1,2; Michael A. Marchetti, MD2
[+] Author Affiliations
1Department of Dermatology, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
2Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Dermatol. Published online August 31, 2016. doi:10.1001/jamadermatol.2016.1966
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To make a definitive diagnosis of skin cancer, dermatologists have been required to obtain skin biopsy specimens of suspicious lesions and to examine tissue pathologic abnormalities ex vivo under light microscopy. In the past decades, high diagnostic sensitivity, which is associated with a low biopsy threshold,1 has been increasingly emphasized in skin cancer screening to combat melanoma deaths and to counter the rising incidence and morbidity of nonmelanoma skin cancer. Distinguishing malignant from benign lesions, however, has always been associated with biopsies of innocuous mimickers of skin cancer, such as nevi and seborrheic keratoses. A 2012 international 10-year multicenter study,2 for example, estimated that 28.4 nevi are biopsied for every melanoma detected. These procedures have been accepted and rationalized as a “cost of doing business”—that is, our accepted set point on a receiver operating characteristic curve that aims to maximize sensitivity for melanoma diagnosis at the expense of specificity.

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Figure.
Melanoma In Situ

A, A 2-cm brown patch with specks of dark brown pigmentation is seen on the shoulder (arrowhead). B, Dermoscopy shows a reticular pattern with focal dots and area with light brown angulated lines. The lesion is suspicious for melanoma on sun-damaged skin. The clinician considered a partial biopsy to secure the diagnosis before proceeding to a large definitive excision. In such a case, reflectance confocal microscopy (RCM) can simulate an “optical partial biopsy” and differentiate with confidence melanoma on sun-damaged skin from solar lentigo. C, An RCM optical section (0.5 × 0.5 mm2) at the level of the dermal epidermal junction shows irregular junctional thickening with dendritic cells (asterisk) and a large, atypical nucleated dendritic cell (arrowhead). The RCM findings are diagnostic for melanoma and rule out the possibility of solar lentigo. Hence, the lesion was excised in toto with 5-mm margins. The final histopathological diagnosis was melanoma in situ, lentigo maligna type.

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