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Original Investigation |

Clinical Indications for Use of Reflectance Confocal Microscopy for Skin Cancer Diagnosis ONLINE FIRST

Stefania Borsari, MD1; Riccardo Pampena, MD1; Aimilios Lallas, MD1; Athanassios Kyrgidis, MD1; Elvira Moscarella, MD1; Elisa Benati, MD1; Margherita Raucci, ARNP1; Giovanni Pellacani, MD2; Iris Zalaudek, MD3; Giuseppe Argenziano, MD4; Caterina Longo, MD, PhD1
[+] Author Affiliations
1Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
2Dermatology Unit, University of Modena and Reggio Emilia, Modena, Italy
3Nonmelanoma Skin Cancer Unit, Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
4Dermatology Unit, Second University of Naples, Naples, Italy
JAMA Dermatol. Published online August 31, 2016. doi:10.1001/jamadermatol.2016.1188
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Importance  Reflectance confocal microscopy (RCM) improves diagnostic accuracy in skin cancer detection when combined with dermoscopy; however, little evidence has been gathered regarding its real impact on routine clinical workflow, and, to our knowledge, no studies have defined the terms for its optimal application.

Objective  To identify lesions on which RCM performs better in terms of diagnostic accuracy and consequently to outline the best indications for use of RCM.

Design, Setting, and Participants  Prospectively acquired and evaluated RCM images from consecutive patients with at least 1 clinically and/or dermoscopically equivocal skin lesion referred to RCM imaging, from January 2012 to October 2014, carried out in a tertiary referral academic center.

Main Outcomes and Measures  A total of 1279 equivocal skin lesions were sent for RCM imaging. Spearman correlation, univariate, and multivariate regression models were performed to find features significantly correlated with RCM outcome.

Results  In a total of 1279 lesions in 1147 patients, RCM sensitivity and specificity were 95.3% and 83.9%, respectively. The number of lesions needed to excise to rule out a melanoma was 2.4. After univariate and multivariate regression analysis, head and neck resulted as the most appropriate body location for confocal examination; RCM showed a high diagnostic accuracy for lesions located on sun-damaged skin (adjusted odds ratio [aOR], 2.13; 95% CI, 1.37-3.30; P=.001) and typified by dermoscopic regression (aOR, 2.13; 95% CI, 1.31-3.47; P=.002) or basal-cell carcinoma specific criteria (aOR, 9.35; 95% CI, 1.28-68.58; P=.03).

Conclusions and Relevance  Lesions located on the head and neck, damaged by chronic sun-exposure, and dermoscopically typified by regression represent best indications for the use of RCM.

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Figures

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Figure 1.
A Lesion Located on the Face

A, Pink facial plaque in a woman in her 70s. B, On dermoscopic examination the lesion revealed fine vasculature and chrysalis. C, Reflectance confocal microscopy (magnification 0.5 × 0.5 mm) showed nucleated dendritic pagetoid cells (arrowheads) suggestive for the diagnosis of melanoma that was confirmed by histologic examination.

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Figure 2.
An In Situ Melanoma Dermoscopically Typified by Regression

A, The lesion, located on the sun-damaged chest of a man in his 80s, is clinically inconspicuous. B, Dermoscopic regression; original magnification ×20. C, Reflectance microscopic examination was able to highlight roundish pagetoid melanocytes (arrowhead) that were diagnostic for melanoma.

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