for me for being here. My name is Caterina Longo and I'm a doctor from Italy and I deal with skin oncology every day in my life and today I'm going to talk about the utility of confocal microscopy in clinical practice. There are clinical evidences that support that this technology is useful and as a general statement we know well that the goal in our life is to get early diagnosis for a better prognosis so ideally we would like to have you know the diagnosis of very small tumors and to get the real diagnosis as much as possible. In medicine we have evidence, utility and also eminence. So talking about evidence for confocal microscopy since the inception of the use of confocal microscopy there were several studies dealing with diagnostic accuracy for melanoma. As you can see here in a very long time frame the first studies were all about rotospective design and they measured the accuracy for melanoma detection by using sensitivity and specificity. So you see that the range of the of the sensibility and specificity ranged from 96 to 70 and it's even higher in some setting and also the number of tumors included is quite different from the setting but there is a common umbrella that is the fact that all the lesions included in these studies were thermoscopically equivocal. So not clear-cut melanomas or clear-cut lesions but only lesions that were challenging based on a thermoscopic point of view. Later on there were two prospectively designed interventional studies, one from Italy and one from Spain. Both included a quite number of lesions 49.3 and 34.3, 343 and they measured the accuracy for melanoma by using the number needed to excise and the number needed to excise was ranging from 6.8 in the Italian setting to 2.9. So excellent data for these two prospective design studies and again the inclusion criteria were the thermoscopically equivocal lesions. Also several studies were defining the criteria, the confocal criteria to make a very subtle and accurate diagnosis for challenging lesions. As you can see here this is a study on the distinction between in situ melanomas from atypical lesions and based on the dermoscopy you see here two false twins and only confocal is able to detect which lesions should be biops. The clinical indication for confocal microscopy were also highlighted in a recently study published on JAMA Dermatology because the main question is, we are very good with dermoscopy, which are the settings for which confocal microscopy can be a very useful tool to increase our diagnostic accuracy. And in these studies also combined by a commentary from Arnold Scope and Michael Marchetti, in these studies we know that in the inclusion of 1,256 studies we got a sensitivity of 95 and a specificity of 83. But basically we confirmed that the number into excise is quite good with confocal microscopy being one out of 2.4. But the main interesting data in my view is that we know well that confocal microscopy outperforms dermoscopy for lesions located on the head and neck areas, meaning that for facial lesion confocal microscopy is by far superior and it's helpful to reduce the biopsy but also to know where to biopsy a given lesion, especially when it's large. And also it's useful for sandemic skin, solution where we do have a lot of sandemic skin, the so-called crocodile skin, in which we do not know whether the lesion is melanocytic in nature or non-melanocytic in nature. In this case confocal is useful. And the third best indication is the lesion where we have regression, meaning that we have very few dermoscopy features. So in the evolution, we have also a kind of evolution of homomedicuse evidence synthesis and finally we have the homococri, and this is the guy I'm talking about. This is the guy that defined the usefulness of randomized clinical trial and of systematic reviews and meta-analysis that pull together all the data from studies trying to get a final answer to the question if it's useful or not a given drug or a given tool in clinical practice. And this is the photos of Archicocrine. So with that said, there were review and meta-analysis, and this is one of that in which the disorders compare dermoscopy and the state, the conclusion that confocal has a greater diagnostic specificity compared to dermoscopy for malignant skin tumors. And here in the graphic, we say the sensitivity and the specificity of confocal microscopy that is much higher by 30% more compared to dermoscopy. And this is another Cochrane library database systematic reviews in which they said, the authors concluded that for the assessment of lesions that are difficult to diagnose for these specific settings, confocal microscopy is better in terms of sensitivity and specificity compared to dermoscopy alone. And further, we know well that in this case, we say the excision of benign lesions, so we spare unnecessary excisions. But lastly, we have the first randomized clinical trial that compares dermoscopy alone as a standard of care to dermoscopy and confocal microscopy in a prospectively designed RCT, the best way to state whether a thing is better to another thing. And we have also to know that there is no RCT for dermoscopy alone. This is a very huge study done in Italy, and it was done in two different centers. Here you see that we have included more than 3,000 lesions. And in this very summarizing graph, we see that we have the same population between men and women. The location is three settings in Italy, and the intervention was to compare confocal alone compared to the standard of care to clinical dermoscopy. And you see in the histogram that confocal microscopy decreased the number needed to excise. This was already known by several papers, but this is the first one proving it in a very good RCT study. So now I'm going to utility. We are clinicians. Utility has a lot of synonyms, but in practice, we know well that confocal has a learning curve for which we have to know whether we are able to learn how to use it in clinical practice. And this just, you know, I don't want to go into the details of confocal criteria, but we know that knowing four key features, we are able to make the diagnosis. So the presence of atypical cells, it's a very good criteria for melanoma. Also the dermal-epidermal junction disarray is another one. And the basal cell carcinoma criteria, as well as the keratinocyte disarray. And the two features, seborrheic keratosis, solanin and tyrosine. But now a practical case from confocal to dermoscopy. Now I want to show you that even if we are not speaking with confocal, if I show you this, you know, we have in mind that we have the presence of this tumoral island with palisading and clear-cut other tumoral island embedded in this bright collagen bundles. When I show this after a 15 minutes lecture to my students, you know, medical students, even after showing you the features of confocal that I showed you before, very briefly, they immediately say, this is a basal cell carcinoma. And this is a basal cell carcinoma also in other frames. But now back to the case, if I showed you, this is the case of that confocal images belong to. This is a patient with this pink nodule on the ear, on your ear, completely unspecific based on clinical. But if I move even to dermoscopy, we see the orange hue and orange colors means pseudo-lymphoma, but also leishmania, sarcoidosis. The presence of atypical lymphocute cells that could be also related to BCC or melanoma. Or why not? Even a chiloid can be the threat because it's also located on the ear where we usually have earrings. So dermoscopy and confocal together increase the diagnostic accuracy for this kind of lesion. And this indeed was a basal cell carcinoma infiltrated subtype. So with confocal microscopy, we close the gap between this pathology and dermoscopy. We know that we are able to detect this very tiny, small entangled maligna. Look, it's just one millimeter in diameter. This is the smallest case that I ever had in my database. And immediately we know that this is a tumor and we need to do a small excision and save patient's life. And I like to conclude that we are not astrologists. We are dealing with patients, but we know that we need evidence. We need cochlear analysis. We need RCT and we have it for confocal microscopy technique. And thank you so much for your attention.

confocal microscopy

skin tumors

melanomas

diagnostic accuracy

evidence-based medicine