Hi, this is Jane Grant Kells again, sharing my enthusiasm for confocal microscopy with you and to show you how you can easily incorporate this into your busy practice. So again, I have no relevant disclosures to share with you. So it was in 2008 that the viviscope was approved by the FDA, and the whole intention was it to assist physicians in forming a clinical judgment. And the question is, does it do that? And I would tell you in a resounding, enthusiastic way, yes. I love it. My colleagues in my department love it. And more importantly, the patients really love it. So how do you incorporate it into your visit? So you identify a lesion, and normally you would say to your medical assistant, set up for a biopsy. But instead of that, you say to your assistant, because it's either a medical assistant or a nurse or an APRN, but it can just be a medical assistant who learns to acquire the images. You identify the lesion and you tell them to please acquire a confocal. And then you go see another patient. So you can stay in the room and evaluate the lesion while it's being acquired or immediately afterwards. And if you do that, and the lesion is benign, you reassure the patient. If it's malignant, you can go to immediate therapy as appropriate. So this is an example of reading it by the bedside while you're acquiring the image. Or you can send it off to a dermatopathologist or somebody who's an expert in reading it who's willing and wanting to get mosaic sent to them through the cloud. So again, you identify a lesion that needs to be biopsied. You ask your medical assistant or whoever you're working with to acquire the image and you go see another patient. And then the image is transmitted electronically for a dermatopathology sign out, which can be done if you alert the dermatopathologist, can be done immediately or will be done later that day. But there's no turnaround time the way there is with a specimen because the images can be read immediately. It's not like a specimen that has to be processed. And again, as mentioned in my previous lecture, images can be transmitted anywhere in the world via the cloud. So let's look at some examples. So this is a patient who had a basal cell on their right forehead, but they couldn't remember the actual site when they came for definitive therapy. And it looked like it was in this area, but we weren't sure. So we got a dermoscopy image and we see the white scar area and we see some dilated vessels that are linear and branching, but they're not really crisp. And there's a pink white area. But the problem was that many of the features that were present in this area were present on other areas of the patient's facial skin. So we weren't sure. So we did a confocal because the dermoscopy was not really 100% helpful. And immediately in the first mosaic in the granular zone, we start to see some shadows or dark silhouettes that are suggestive of basal cell carcinoma. Please notice that the collagen around it now looks white because it's fibrotic. This is the dermis poking up. And here you see the honeycomb for the epidermis. The skin is not flat. Let's get a little closer to these silhouettes. So this is the silhouette. You can see cells composing this dark silhouette. You can see even some stromal retraction and the white collagen around it because it's thickened. Similarly here, the collagen is thickened and these are the dark silhouettes that are composed of basal cell carcinoma with some stromal retraction. And similarly here, dark silhouettes thickened now more refractile collagen. You also sometimes can see dendritic cells. As we all know, these are melanocytes and some basal cell carcinomas have some scattered melanocytes within the tumor aggregates as well as melanin within the tumor aggregates. And if it has a lot of that, they look like pigmented basal cells. They're more pigmented clinically. And that's just the dendritic melanocyte in higher power. Then there, you could also see these linear or what we call canalicular blood vessels, which is characteristic of what we see in a basal cell carcinoma. And sure enough, on biopsy, this was a basal cell carcinoma. So we identified the correct area for definitive surgery. So if you go and look at the confocal features for a basal cell, which you've gone over in another course, we saw in this particular case, tumor islands, fibrotic or refractile collagen, linear canalicular vessels, and some dendritic cells that were melanocytes within the tumor islands. So we knew immediately where to do our surgery. Let's look at another example. 44-year-old woman has a history of melanoma in situ and noticed a little pale brown area on her nose that was of some concern to her because it was near the site where she had the melanoma. When we do our dermoscopy, we see two kinds of areas. We see this morth-eaten area, which almost has these fat fingers of cough that we think of in a solalentigo, but we also have some of this grayish brown pigment lining the hair follicle and obviously some scar. So we're going to do two confocals. We're going to do a confocal of this area and a confocal of this area to determine where the melanoma is. And when we do a confocal of the area number one, we see the fat fingers of cough correspond to these bulbous projections of epidermis that are hyperpigmented, as you would see in a lentigo. So that represented a solalentigo. And this is what it looked like under the microscope, hyperpigmented basal keratinocytes and the bulbous projections with the hyperpigmented epidermal hyperplasia at the DE junction. If you go around this circle here, we worry now, is this pigment or melanocytes descending down the hair follicle? So we did a stack and we're going down the hair follicle. And as we go down, we see these bright rounded and dendritic refractile cells that represent atypical melanocytes going down the hair follicle. And that we know is a feature of lentigo maligna. And this was a recurrence of the melanoma in situ. Here you have the atypical melanocytes at the DE junction. And here you have the atypical melanocytes going down the hair follicle. Another case, 71-year-old with psoriasis and a history of non-melanoma skin cancers, has this lesion on his arm that he thinks is psoriasis, so he's been treating with topical steroids. When you look at this with your damoscopy, you see some fine branching vessels and some pink-white areas, but it's not very specific. So you're not sure what you're dealing with. As soon as you get your first mosaic, you will see that the honeycomb pattern is very atypical, and there's scale crust and inflammation here. Let's zoom in, and you can see the bright crust and the tiny refractile cells represent inflammatory cells. So we have scale crust. Now let's look at the epidermis. And when we get closer, we see how atypical the honeycomb pattern is. This nuclei are angulated, the cytoplasm is variable in size and thickness, and the beautiful honeycomb pattern is no longer present. So we have a disarranged honeycomb pattern. Look how the nuclei, which are not very refractile, are angulated and irregular in size and shape, and the cytoplasm is variable in thickness and shape. So we have an atypical honeycomb, scale crust, and when we get down to the papillary blood vessels, we can see in the dermal papillae that they are vertically oriented, which is sometimes called the buttonhole sign. So we knew from the confocal that this was an atypical squamous lesion, it was not psoriasis, and so a biopsy was undertaken, and this was, of course, Bowen's disease. And the vertical vessels that we saw in the buttonhole sign are seen on histology, and the full thickness squamous atypia, creating the atypical honeycomb, is also seen on histology. And so when we know our features of a squamous cell, we saw scale crust and parakeratosis, atypical honeycomb, and the buttonhole sign, rounded, vertically oriented blood vessels in the dermal papillae. And so we knew confocally that this was a Bowen's, and that was confirmed histologically. So the bottom line is, you can easily incorporate this into your practice, instead of doing a biopsy. You go to another room and see a patient, and your assistant acquires the confocal. You bill for the acquiring of the confocal under the MD name, because you're the provider, and you can either interpret the mosaics and bill for that, or you can send the mosaics via the cloud to a specialist who can read them for you, and they will bill for the interpretation of the mosaics. But this technology will spare your patients unnecessary biopsies. It will make the diagnosis earlier for you on lesions that you're not sure about, but you don't really want a biopsy. It'll identify the correct site for surgery, if you can't find it clinically, and the patient has forgotten the site. You can use it to evaluate lateral margins, so you know how wide an excision or Mohs anticipate, and how large the Mohs defect will be. And you can absolutely incorporate this into a derm practice. I also use this often when I treat lesions with immunotherapy or topical chemotherapy. I often use confocal to ensure that the lesion has been successfully treated. Thank you for your attention.

confocal microscopy

clinical practice

diagnosis

basal cell carcinoma

melanoma