I am Jane Grant Kells, and I am at the Department of Dermatology at the University of Connecticut Health Center and Medical School. And I am thrilled to be able to share with you my enthusiasm and what I know about reflectance confocal microscopy and how you can incorporate it into your practice. I have no relevant disclosures to share with you, but I want to thank, before we get started, Harold Rabinovitz and Maggie Oliviero Rabinovitz. Harold and I trained together in dermatology, and he and I have been friends. And he is the one who introduced me to confocal and has taught me all that I know. And I am very grateful to him and Maggie for their mentoring. So we know that the dermatoscope is a wonderful bridge to what we see under the microscope. And I hope I'm able to convince you, in the time we have together, that the confocal microscope is as good as the microscope and can avoid biopsies. So what is confocal microscopy? Confocal microscopy is a high-resolution, non-invasive imaging device. And it allows you to see, on a cellular level, the epidermis, the dermal-epidermal junction, and the superficial dermis. And you can see it on a cellular level in horizontal sections. So when you go into a room and you identify a lesion that you're worried about, you do a biopsy. And then the pathology lab generally orients it and cuts it vertically. They really only get to inspect a very small percentage of the lesion. But with confocal microscopy, we look at the lesion on FOS, or horizontally, the way a Mohs surgeon does. So we can see much more of the lesion, up to a lesion 8 by 8 millimeters. So more of the lesion is evaluated. And the great news is that there are really zero adverse events associated with this technology. So how does it work? The confocal microscope uses a low-energy diode laser that is directed to a small area of the skin. The light is then transmitted back through a pinhole up to a detector. And that detector is able to convert the pixels into an image. And you get the image right in real time at the bedside in horizontal sections, the way a Mohs surgeon would look at slides. The depth is only to about 250 microns. So you get to see the DE junction and some of the papillary dermis, but very rarely the reticular dermis. And the technology relies on the different refractive index of the elements of the skin. So for example, you're going to see images that are in black and white and gray. And brighter colors mean more refractility. Brighter light means more refractility. So keratin, so if it's hyperkeratotic, the lesion is scaly, the keratin will be very refractile. Hair is very refractile. The skin is very refractile. Melanocytes or anything with melanin, so even pigmented keratinocytes will look very bright. And interestingly, the activated or reactive Langerhans cells, their Burback granules are very refractile. The cytoplasm of keratinocytes are very refractile as opposed to the nucleus. So the nucleus will look dark and the surrounding will be bright. And finally, collagen that is not altered is not very refractile. If it's altered, fibrotic, or it has evidences of solar elastosis, then the collagen will be very refractile. And I'll show you examples of this. The image that's acquired is in 500 by 500 boxes that the computer stitches together into a mosaic that's up to 8 millimeters in diameter. Again, captured in a horizontal plane. And so we get images that are stitched together at various levels of the epidermis and papillary dermis. Now, the confocal does allow us also to get a stack. And a stack, if you see something of interest clinically or with the dermatoscope, you can get a stack right over that area. For example, pigment around a hair follicle, if you want to study that more closely. The stack, however, is less than a millimeter in diameter. So it's very small. When you see the images on the left that are confocal images versus the histologic images horizontally in black and white, you can see how similar they appear. So the stratum corneum, the granular layer, the stratum spinosum, the DE junction, and the papillary dermis, whether by histology or confocal, look quite similar in black and white. Unfortunately, the dyes that we could use to color the images are toxic. And so they cannot be used in vivo. So what does normal anatomy look like? Well, if you're up in the stratum corneum, you're going to see large polygonal cells that are very refractile because they have a lot of keratin. And obviously, in the stratum corneum, there are no nuclei. So you don't see any dark circles or holes in the cells. If you did see nuclei, that would represent perikeratosis. When you go down to the granular zone, you get this honeycomb-like appearance where the nuclei are dark and the surrounding cytoplasm is more refractile. Remember, I said the nuclei are not refractile, so they look dark. The cytoplasm is more refractile, so that looks bright. The cells are very similar in size and shape, and it has a honeycomb appearance. In the granular zone, it's a little hazy or granular in appearance. When you go down to the stratum spinosum, it's a little bit more crisp. And please notice that the cells are smaller. The cells, as you descend down to the basal cell layer, actually get smaller. But the honeycomb pattern persists. And so you see the dark nuclei and the bright cytoplasm. When you get to the papillary basal layer, remember that in the basal cell layer where most of the pigment is located in the skin, the basal keratinocytes have a lot of melanin. And so those cells will be refractile, and that's what you're seeing here. Each cell that's bright represents a basal keratinocyte above the dermal papillae and the superpapillary plates, and that's why they're clustered. So each of these represent hyperpigmented and therefore refractile basal keratinocytes. So some of the terminology we've used, just to repeat, we've used honeycomb. And when the honeycomb is typical, that's what we see in a normal epidermis. Where the nuclei are dark, the cytoplasm is bright, and the cells are pretty much in the same size and shape. And as you descend deep into the dermis, that's how you can tell where you are because the cells diminish in size. This was loaned to me by Alon Scope, a dermatologist in Israel, and you can see in cross-section a confocal and what an H and E of the epidermis would look like in cross-section, and you can see why you get this honeycomb pattern. So these are four examples of typical honeycomb patterns with the nuclei and the cytoplasm for most of the cells are pretty similar to their neighbors. In contradistinction to that, this is atypical honeycomb. And in the atypical honeycomb, the nuclei are variable in size and shape and sometimes are actually angulated in appearance. And notice that the cytoplasm is variable in how refractile it is and how thick it is and its shape. And this would be atypical honeycomb. And this we would see obviously in an atypical squamous lesion like a squamous cell carcinoma, actinic keratosis, Bowen's disease. Sometimes the honeycomb is totally nuked and it's what we call disarranged. Here we are in the epidermis and you can sort of see some nuclei and cytoplasm, but the honeycomb pattern is almost unrecognizable and we call this a disarranged pattern. And here are four examples of disarranged pattern where the honeycomb pattern is basically no longer obvious. You can see some nuclei and cytoplasm, but that beautiful honeycomb pattern is gone. I want you to notice this dendritic cell that's refractile and that is a melanocyte because sometimes the honeycomb can become atypical when cells that are not supposed to be there are present in the epidermis like melanocytes in a melanoma. So when you see an atypical honeycomb, most commonly it's going to be due to an atypical squamous process, but you have to make sure that nothing else is going on like atypical melanocytes in a melanoma. When you get to the basal cell layer, the bright refractile basal keratinocytes make these bright cells that resemble a cobblestone pattern or stars in the sky. And as you recall, each of these bright areas represent hyperpigmented, therefore refractile basal keratinocytes. So each of these cells corresponds to each of these cells in the super papillary plate and represent hyperpigmented basal keratinocytes and they're clustered because they're above the dermal papillae. And this is a normal cobblestone pattern where the cells are pretty much all of the same size and shape and refractility. This is another example where you at the super papillary plate area where you see these clusters of hyperpigmented basal keratinocytes. We're going to zoom in. And here you see the super papillary plate, hyperpigmented basal keratinocytes. And whether the cobblestone is these clusters or each cell, it is irrelevant. Basically, it's a uniform normal pattern. Now, in contradistinction to that, this is an atypical cobblestone pattern. And here you can see that the cells that are refractile are variable in size and shape. Some of them are even nucleated. See the hyporefractility of the nucleus here? So you have refractile cells that are variable in size and shape and some of them are nucleated. And this is called an atypical cobblestone. And when I see an atypical cobblestone, I am very worried about an atypical melanocytic lesion. You can even see some refractile dendritic cells here. So this is an atypical cobblestone where the cell size and shape and refractivity is variable and some nucleated cells may be even present and some dendritic cells may be present. So when you see an atypical cobblestone, that's very worrisome. And when you see a typical cobblestone, that's benign and can be seen in lentigo, a simple, a solo lentigo, a simple lentigo or a junctional nevus. When you get to the DE junction below the superpapillary plate of the basal keratinocytes, now you're in the dermis, but there are reti on either side. And so you sort of get what I look, I refer to as donut, a donut sign where you get these edged papillae. So this is the dermal papillae that's dark. Remember collagen is not very refractile and the basal keratinocytes have melanin. And so they're refractile and they're lined up around the dermal papillae. And that's what it would look like if you were looking down on this. This is the hole and these reti lined by hyperpigmented basal keratinocytes form the ring or the edge around the dermal papillae. So the center represents the darkness is the dermis, the dermal papillae, because the collagen is not very refractile. And the edge is composed of hyperpigmented basal keratinocytes. And these form edged papillae. And I like to, the analogy I like is like soldiers lining up around the dermal papillae, each of these basal keratinocytes. And these are four examples of edged papillae. This is a heart because I love confocal, but the dermis, some of these bright cells within the dermal papillae are melanophages. And we'll talk about that later, the predominant feature here in each of these mosaics is edged papillae. Now in contradistinction to that, this is non-edged papillae. Our little soldiers are no longer lined up, they're in a mess. And the epidermis is a little thickened. And if you look carefully, you can see refractile and dendritic cells. And these are atypical melanocytes. When I see non-edged papillae, I also worry about an atypical melanocytic proliferation because the melanocytes are atypical and within the epidermis and thickening the DE junction and the hyperpigmented basal keratinocytes are in disarray and no longer lined up along the dermal papillae forming edge papillae. So we now have non-edged papillae. So these are two examples of non-edged papillae. These are the dermal papillae. We no longer have our soldiers of basal keratinocytes forming sort of the sugar donut around the dermal papillae and you have scattered in the epidermis these refractile cells that are atypical melanocytes. So non-edged papillae are bad and edged papillae are good. When all the papillae, when you get down to the DE junction down this level you see all edged papillae. We call that the ring pattern and the ring pattern can be seen in a lentigo or a junctional nevus or in a compound nevus where there are not large nests of nevus cells at the DE junction. And again this is called the ring pattern because you have lots of rings of edged papillae. When you have larger nests of nevus cells at the junction, either of a junctional nevus or a compound nevus, the DE junction gets thickened and forms what we call a meshwork pattern. And here you have the meshwork pattern and you can see thickening of the DE junction from bridged nests of melanocytes or nevus cells at the DE junction. And you can also see discrete rounded nests of nevus cells at the DE junction in this meshwork pattern. And again we see this in junctional nevi and compound nevi. When I get to the dermis, I can see many of the structures I can see with a microscope. I can see nests of melanocytic nevus cells. Again, notice the edged papillae, the dark dermal dermis. The collagen is not altered so it's not refractile and we have a round aggregate that's well circumscribed and more refractile and that represents the and more refractile and that represents, and it's not connected to the epidermis, so that represents a nest of melanocytic nevus cells and in an intradermal nevus. If you see bright stellate cells, often without nuclei, though in the papillary dermis, those represent melanophages. And the collagen that is normal is fibrillar and not very refractile. If it's altered by solar elastosis or fibrosis, the collagen will become brighter and more refractile. So it's fibrillar and when you acquire the images there's no motion. And the reason I mention motion is because when you acquire the images you can see the blood coursing through the blood vessels, which is very cool. And there are two types of blood vessels that are easy to identify. If the blood vessel is running horizontal to the surface epidermis, it's going to look like a snake or a canal and we call that canalicular. If it's oriented vertical to the surface epidermis, it's going to look like a big hole, but you're going to see the red blood cells coursing through this and so they'll be very easy to identify. You can see adnexal structures like hair, which are very refractile. Again, notice all the edged papillae forming a ring pattern and here is the hair. And you can see other adnexae. This is sebaceous gland and you can see the nuclei which are dark and the cytoplasm which is more foamy and more refractile in this sebaceous gland lobule. Now I trained with Bernie Ackerman when I did my dematopathology training and he was big into pattern analysis. And I use that similar technique when I sign out my confocal lesions. We've talked about some of the patterns we already see and there are many more patterns that you'll see in other lectures by various specialists in this course. But we've talked about the honeycomb pattern, the cobblestone pattern, the edge versus the non-edged papillae pattern, the meshwork pattern, the dermal nevus pattern is called the clod pattern, similar to clouds in the sky. And when you see basal cell, we call that tumor islands. As you can see here, the island which is irregular but distinctive from the surrounding water. And I will show you some examples of tumor islands in basal cell. What's the workflow like? Well, the first thing you get, you have to acquire is a dermoscopic image. That's part of the whole workflow. And it is the combination of dermoscopy and the confocal mosaic that gives us this amazing sensitivity and even high specificity, which is why this is our technology. This doesn't belong to any other specialty because we're the only ones that are experts in dermoscopy. So the confocal image can be as large as eight by eight millimeters, but the dermoscopic image can be as large as one centimeter. After the dermoscopy is acquired, we then get confocal images. I like to get four to six mosaics, stratum corneum, stratum granulosum, stratum spinosum, basal cell layer, DE junction, and papillary dermis. The more I get, the better I can make my sign out. And you can either read these at the bedside or send them to a remote specialist who can read them similar to the way you send a biopsy to a DermPath lab. So if you read them at the bedside, you get an immediate answer. You can reassure the patient that it's benign, or you can go to definitive therapy. If you see a basal, you can ED and see it, or excise it, or use immunotherapy, whatever you decide is the best, but you can do it right there. So this is me explaining to a patient what I'm seeing. This is my medical assistant who acquired the image, and I was explaining to the patient why a biopsy needed to be done. But if you don't want to learn how to sign out these mosaics, you can capture the image and send them just as you sent a specimen to a lab. You can send the image to the cloud, and it gets transferred to the dermatopathologist who then can read it on their computer. And they can read it anywhere in the country. So when I'm in Florida, because I'm an older dermatopathologist, I spend the winter in Florida, I can read my Connecticut confocals, and I can also read confocals from various states around the country if I have a license in that state to practice medicine. I can also share cases with people all over the world. When I go to my laptop, I go to this page where I can see cases I've signed out, which are checked, and cases I need to sign out. I select the patient case and click on it, and I get clinical information. And then I can see the dermoscopic image and the confocal images, and then I sign it out. This is the sheet that I can see. I get the lesion information. I get why the clinician was concerned about the lesion in the past medical history. I then see my dermoscopic image, which is very helpful to me. I then can also see where stacks were acquired, which has made me even more of an expert in dermoscopy because of incredible dermoscopic pathology correlation. And then I go to the mosaics. And then I sign it out like a PATH report with the dermoscopic image. I select a confocal image and take a picture of it and add it to the report. And I can even make recommendations so I can type anything I want onto the report that I feel is relevant. Now, if you're busy the way we are at UConn Derm, and you have computers where you're writing your notes, your electronic medical record, which is making you crazy like it makes me crazy, you may not have time to do a full confocal. We have been talking about the viviscope 1500. These are the only confocals that are now produced in the world, viviscope 1500 and viviscope 3000. We've been talking about the one that creates the mosaics, but there is a handheld device called the viviscope 3000 that you can acquire as well. And it's very much quicker and easier to use. It was introduced a few years after the standard confocal. It was introduced in 2011. It's small, it's portable, and most importantly, it has a much smaller head or tip. So it gets into areas that you might not be able to get a good contact with for this larger head. And it's very quick and simple to use. Unfortunately, it does not have a CPT code as of yet. It is again quicker to use. It only can do stacks. You can't get a mosaic. It has the ability to get into small areas like along the nasolabial fold, along the creases of the ear in between the fingers. And it has as high sensitivity and specificity as the traditional confocal. So this was an example of it being used in the crease of the nose was an area of concern. Six years after Mohs surgery, a stack was done with the handheld device. And you can see the tumor islands on all the images on the stacks of the basal cell. So we knew this was a recurrence. The question is, do you think does confocal work? And the answer is absolutely. It is incredible. It has a very high diagnostic accuracy. It reduces unnecessary biopsies. And it can spare patients unnecessary pain and suffering. The sensitivity and specificity have been shown in the hands of many people to be incredibly high. This was a more recent lesion that was published that showed that it avoided unnecessary biopsies. And in some cases, when the lesion was decided to be treated non-surgically, it avoided a biopsy completely. And it picked up lesions that were missed on domoscopy. And what I like about confocal is that about 60% in some people's hands, more than 70% of the lesions that are confocal are benign and don't need a biopsy at all, which is tremendously important and helpful to patients. And again, the clinical and dermoscopic and confocal information is what gives you this incredible accuracy of sensitivity and specificity and positive predictive value and negative predictive value. So you rarely will miss a neoplasm. And that makes us superheroes, I think. And there are codes. Since 2017, there are CPT codes. You can see that the RVU is pretty similar to what you would get acquiring a confocal or doing a biopsy. The amount of money you get is similar. And interpreting the slide versus interpreting the confocal mosaic, again, the RVU is pretty similar. And the financial remuneration is pretty similar. And every year, this changes, but again, remain pretty similar. We did a study a few years ago at UConn where we tried to decide whether does confocal save us money? So we did a number of lesions over a course of many months, and we extracted collections that were obtained from confocal, subsequent biopsies and excisions versus what the anticipated costs would be if every lesion would have been biopsied. And we used one single excellent clinician, not myself, one of my colleagues, and we only used lesions that she was worried about and would have biopsied and opted to confocal those lesions. And then because it was a study, we biopsied them anyway. And we financially worked on the scenarios to see, does confocal save money if you were going to biopsy every single lesion? And what we found is that if we were going to biopsy every single lesion, it would have been almost 96,000. But if you included the cost of confocal, even if you repeated the confocal, the course for that subsequent biopsies and excisions, it was a major saving of money. And then we played with the data to try to make sure that we weren't being biased. So for those air lesions that we had incomplete follow-up, we played with the data. And for those lesions where we had missing follow-up and we assumed that they were biopsied at the rate of the highest payer insurer, we still saved money. So no matter how we analyzed the data, doing confocal microscopy as part of your workflow saved healthcare dollars and spared patients unnecessary biopsies. So the bottom line is the dermatologic surgeon and the dermatopathologist behind the microscope can in many cases be replaced by confocal microscopy. And money is saved when you incorporated it into your practice for healthcare dollars, because there is no fee to handle the actual tissue of the biopsy, which is the most expensive part of the dermatopathology fee schedule is what's paid for handling the tissue, not the professional component that's paid to the physician. And so excluding that using confocal microscopy causes the healthcare system and insurances to save money. Thank you very much for your attention.

reflectance confocal microscopy

dermatology

non-invasive imaging

skin conditions

melanocytic lesions

basal cell carcinoma

University of Connecticut Health Center