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Original Investigation
October 2016

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

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. 2016;152(10):1093-1098. doi:10.1001/jamadermatol.2016.1188
Key Points

Questions  When is reflectance confocal microscopy (RCM) most useful in clinical practice?

Findings  In this study of 1279 equivocal skin tumors referred for RCM consultation, we obtained a diagnostic sensitivity of RCM was 95.3% and specificity was 83.9%. Reflectance confocal microscopy was most useful for lesions located on the head and neck, lesions with clinical evidence of sun damage, and those with evidence of regression on dermoscopy.

Meaning  Reflectance confocal microscopy is a useful tool for the diagnosis of challenging lesions suspicious for malignant abnormalities.


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.