So this is part two, how to utilize RCM in a busy clinical practice. And one of the ideal areas to use the reflective confocal microscope is on facial lesions, and for two reasons. Patients don't want to have a scar, and physicians need to have an adequate biopsy for the pathologist to make a diagnosis, and that is often a quandary. So when you have a gentleman such as this with a history of melanoma, he notices an enlarging pigment lesion of the chin, the outlier lesion. He's extremely concerned, however, about a biopsy and scarring. And with dermoscopy, we use both contact nonpolarization and contact polarization. Our differential would be a pigmented actinic keratosis versus a melanoma in situ. In the contact nonpolarized mode, we see these white circles with these keratotic plugs. In the polarized mode, we get more information, including these four white points, which are called rosettes, this red pseudonetwork, and white projections. And this is often characteristic of a pigmented actinic keratosis. So it has features suggestive of a pigmented actinic keratosis. And immediately, you think, well, perhaps we can just use one of the topical creams, whether it be 5-fluorouracil or in combination with 5-fluorouracil and calcipetriene or perhaps even imiquimod. Or should one perform a biopsy? Well, what does RCM tell us? Well, here we are at scanning magnification of the spinous granular level. And what we see here are these spindle-shaped structures. We have a typical pattern, a honeycomb pattern, with these dark oval areas. And on higher magnification of this area where you have these spindle-shaped structures, what you see are they're surrounding the hair follicles. And on higher magnification, you can see that there are sheets of dendrites. So here's what we see clinically and now with confocal. And this is characteristic of a melanoma on sun-damaged skin. And excisional biopsies perform. And the diagnosis with immunostains is melanoma in situ. Another lesion, this gentleman with this lesion, isolated lesion on his chin. Here we see what are called angulated lines in gradox granules or regression structures. So we're thinking this too is a melanoma on sun-damaged skin. And here one sees these slightly broadened honeycomb pattern. And over here are these spindle-shaped bright cells infiltrating the epidermis. At a little different area, we see these dendritic cells. And they're aggregated around the hair follicles. And we actually call this the head of Medusa. These two are all classic for melanoma on sun-damaged skin. The patient's referred back to his referring dermatologist who performs a shave biopsy. And it's read out as a lenigo. And yet, if you look very carefully, perhaps there are some melanocytes above the epidermal junction. And at this point, we recommend an excisional biopsy. And when an excisional biopsy is performed, here one sees, with immunostains, the classic melanoma in situ on sun-damaged skin. With this young woman who has this enlarging, isolated pigmented lesion of the lip, she prefers not to have a biopsy and is concerned about a scar. Now, with dermoscopy, the overall pattern is very, very subtle. But on higher magnification, you can see these circles with this gray rim. And any time you see gray circles, it's one of the melanoma-specific features with dermoscopy. Although it doesn't have the pattern of a melanoma on sun-damaged skin, perhaps atypical melanocytic hyperplasia. So confocal is performed. This is high up in the skin. It's relatively atypical honeycomb pattern. And as you go deeper, you see these widening of the interpapular spaces. And the dioxys is really made a little deeper, where we see what are called cords. And these elongated cords are very, very characteristic of a Lenigo early seborrheic keratosis. For this particular patient, what we see is another isolated lesion, which is an outlier. Any time you have an outlier lesion, melanoma must be in the differential. And dermoscopically, however, it had some moth-eaten borders. It had some gray dots, granules, some brown dots, perhaps some brown structures, which are somewhat linear. With RCM, this is the spinous granule level. There's an atypical honeycomb pattern. And there are some areas where it looks as if there are areas that are elevated and depressed. And if we zoom in this area, we see that the whole spinous granule level is atypical. That is, these cells are big and large, and we call these pleomorphic cells. At the D-junction, we see a different pattern. We see this pattern of these small circles with bright white rims. When we see this, this is pathodigmotic for a pigmented squamous acorcinoma in situ, where you have this full thickness atypia with the basilar hyperpigmentation. In this particular case, it was a gentleman who comes in concerned about this spot on his neck. And dermoscopically, as well as confocally, this is melanoma. And excision was performed with 5-millimeter margins. This is one week post-excision, and this is three weeks post-excision. And indeed, a melanoma in situ. Now, the same gentleman had this very subtle area on his cheek. Dermoscopically, it was non-diagnostic. But given the fact that he had another melanoma, this did concern me. And the question mark is, what do you do? Do you monitor this? Do you biopsy? Do you do a punch biopsy, which is essentially not particularly helpful? If anything, perhaps an incisional biopsy would be best. But yet, you don't see much. Now, with RCM, however, if you're here at the spiny granular level, as you go a little deeper and zoom into this area where you have the honeycomb pattern, you already see dendritic cells. These are dendritic cells high up in the epidermis, now at the DE junction. What we see here are these sheet-suspendal-shaped structures scattered through the interpapillary spaces and around the adnexal structures and the follicular openings. And if you zoom on this area, you see the numerous dendritic structures surrounding the hair follicles. So what we elected to do was an excisional biopsy. And this patient then normally is scheduled a couple weeks afterwards if it is positive. And we were convinced that it would be positive. This is three weeks post-excision. And the pathology indeed demonstrated a melanoma in situ on sun-damaged skin. Two lesions. These two patients came in a week apart. Both isolated lesions, outliers on the upper back. And here you can see the dermoscopy patterns. So the first gentleman had this outlier lesion. Dermoscopically, it had a reticular homogeneous disorganized pattern with this atypical network. And these are features suggestive of either an atypical melanocystic nevus or a melanoma. And a biopsy is needed. With RCM, there are these small bright cells which are infiltrating the epidermis. And on higher magnification, you can see that they're both pagetoid cells. These round cells with this dork center. And these dendritic cells are spindle-shaped cells. And this is characteristic of melanoma just based on the features we see in the epidermis. At the DE junction, there is both an atypical ring and meshwork patterns. And here we can see these bright cells infiltrating the rim of the rete, as well as bright cells infiltrating in between the interpapillary spaces. And this is characteristic of a malignant pattern and excisional biopsies performed. A melanoma, 0.35 millimeters. The other lesion, who had an outlier lesion on his back, had this pattern. And this is what's called a reticular homogeneous pattern. There are some focal streaks or focal peripheral globules. And these features, too, are usually suggested by either an atypical melanocytic nevus or a melanoma. With RCM, it has a normal pattern, a typical honeycomb pattern. And on higher magnification, there are no pagetoid or dendritic cells, which is very important. And all that one can see are these monomorphic cells. And these monomorphic bright cells give you what's called the cobblestone pattern, which are characteristic of pigmented keratinocytes. And at the DE junction, if we zoom in on this particular area, we have these polymorphous pilla, the bright cells between the interpapillary spaces, and this mili-like cyst. And these, too, are all characteristic of a benign lesion, a congenital nevus or a nevus with congenital-like features. And this lesion of biopsy is not performed, and the patient is seen back in three months for mole monitoring. So what we have here are two lesions, a week apart, similar in the fact that they're both outliers, both clinically as well as dermoscopically with atypical patterns. And yet one is a melanoma, and the other is a congenital nevus. Now, this was a young woman who had an atypical spitoid lesion a few years back on her leg, and she presents with this pink lesion on her chest. Really doesn't want a biopsy or scarring. And it's tough clinically to say whether or not this is just a lichen planus-like keratosis, an actinic keratosis, or an early squamous cell. And dermoscopically, it was more suggestive of either an actinic keratosis or a lichen planus-like keratosis. We did see, actually, some rosettes. Rosettes we usually see with actinic keratosis, but occasionally we see them with lichen planus-like keratosis as well. With RCM, this is a normal, typical honeycomb pattern, completely normal. At the D-junction, we have these anastomosing cords, and in between the cords here, you have these bright cells, which are melanophages. And this is lichen planus-like keratosis, and this lesion is not biopsied. And actually, we treat this patient with some topical steroids, and you can see how beautifully she did. And this lesion here on the back, it's another outlier. These outlier lesions, you have to concern yourself for early melanomas on sun-damaged skin. It has this atypical network with great ox granules. And with RCM, high up in the epidermis, we saw these spindle-shaped cells. At the D-junction, there's loss of the normal architecture. If we zoom in this particular area, you can see that there's a component at the D-junction where you have these spindle-shaped structures. And yet, when biopsied, it's read as a dysplastic nevus. But is it really? Because you certainly do have these cells above the epidermis, and certainly another dermatopathologist might consider this an early melanoma. And this is a challenge where the confocal diagnosis does not match the pathology diagnosis. So we have another gentleman such as this with this outlier lesion, and dermoscopically, it has the features we see with melanoma on sun-damaged skin, with great ox granules, the scar-like depigmentation, and this faint network at the periphery. And when we recommend to do a biopsy in this type of instance, very often we'll just excise with a 5-millimeter margin, because if it is read as a high-grade dysplastic nevus or melanoma in situ, no further treatment is necessary. And when the biopsy comes back as a high-grade dysplastic nevus, if we see features such as this, which are suggestive of melanoma, second opinions are always important in this instance. Two other dermatopathologists felt this was melanoma in situ. Or in this woman, who has an outlier lesion, clinically, dermoscopically, and confocally, here we see these cells infiltrating the retae, and it comes back as a high-grade dysplastic nevus, you have to question your pathologist. And when reexamined in deeper sections and multiple sections were performed, an invasive melanoma in situ. And the important point of this is that when the pathologist makes a diagnosis of a high-grade dysplastic nevus on the face, you have to be very, very concerned that, indeed, this is a melanoma in situ. Thank you for your attention.

Reflective Confocal Microscope

skin lesions

melanoma

diagnosis

dermoscopy