What is the role of confocal microscopy in melanoma diagnosis?

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Clinical practice guidelines for the diagnosis and management of melanoma > What is the role of confocal microscopy in melanoma diagnosis?

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Reflectance confocal microscopy

In vivo reflectance confocal microscopy (RCM) is a non-invasive technique that allows examination of the skin with cellular resolution. A systematic literature[1] search up to 24 December 2015 reports on a total of 21 studies involving 3108 patients with a total of 3602 lesions included in the per-lesion analysis: The corresponding pooled results for sensitivity and specificity were 93.6% (95% CI: 0.92-0.95) and 82.7% (95% CI: 0.81-0.84) respectively for the diagnosis of malignant lesions. Positive likelihood ratio and negative likelihood ratio were 5.84 (95% CI: 4.27-7.98) and 0.08 (95% CI: 0.07-0.10) respectively. Subgroup analysis showed that RCM had a sensitivity of 92.7% (95% CI: 0.90-0.95) and a specificity of 78.3% (95% CI: 0.76-0.81) for detecting melanoma.

In May 2015 the Diagnostics Advisory Committee of the National Institute for Health and Care Excellence (NICE), UK reviewed the evidence available.[2]

The Committee considered the quality of the studies included in the systematic review of clinical effectiveness and concluded that studies from 2013 onwards were most relevant to the assessment.[1] Concerning studies focused on melanoma diagnosis, the following were considered the most relevant: Alarcon et al. (2014)[3], Pellacani et al. (2014)[4] Ferrari et al. (2014)[5], Stanganelli et al. (2014)[6], and Rao et al. (2013)[7].

The Committee considered the evidence on using the VivaScopeR systems after dermoscopy, to rule out biopsy and excision of equivocal skin lesions in people with suspected melanoma reported similar sensitivity values, but higher specificity values for the VivaScope systems compared with dermoscopy alone. The Committee concluded that the evidence suggested that imaging using the VivaScope systems after dermoscopy had a higher negative predictive value than dermoscopy alone.[1] In term of cost/time efficiency, it seems to save over 50% of benign lesions from unnecessary excision.[3][4][8][9]

Lesions located on the head and neck, damaged by chronic sun-exposure[10][11], lesions dermoscopically typified by regression[12] and amelanotic tumors[13][14] represent the best indications for the use of RCM.


  1. 1.0 1.1 1.2 Xiong YD, Ma S, Li X, Zhong X, Duan C, Chen Q. A meta-analysis of reflectance confocal microscopy for the diagnosis of malignant skin tumours. J Eur Acad Dermatol Venereol 2016 Aug;30(8):1295-302 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27230832.
  2. National Institute for Health and Care Excellence. VivaScope 1500 and 3000 imaging systems for detecting skin cancer lesions. United Kingdom: NICE; 2015 [cited 2017 Jan 12] Available from: https://www.nice.org.uk/guidance/dg19.
  3. 3.0 3.1 Alarcon I, Carrera C, Palou J, Alos L, Malvehy J, Puig S. Impact of in vivo reflectance confocal microscopy on the number needed to treat melanoma in doubtful lesions. Br J Dermatol 2014 Apr;170(4):802-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24124911.
  4. 4.0 4.1 Pellacani G, Pepe P, Casari A, Longo C. Reflectance confocal microscopy as a second-level examination in skin oncology improves diagnostic accuracy and saves unnecessary excisions: a longitudinal prospective study. Br J Dermatol 2014 Nov;171(5):1044-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24891083.
  5. Ferrari B, Pupelli G, Farnetani F, De Carvalho NT, Longo C, Reggiani C, et al. Dermoscopic difficult lesions: an objective evaluation of reflectance confocal microscopy impact for accurate diagnosis. J Eur Acad Dermatol Venereol 2015 Jun;29(6):1135-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25303304.
  6. Stanganelli I, Longo C, Mazzoni L, Magi S, Medri M, Lanzanova G, et al. Integration of reflectance confocal microscopy in sequential dermoscopy follow-up improves melanoma detection accuracy. Br J Dermatol 2015 Feb;172(2):365-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25154446.
  7. Rao BK, Mateus R, Wassef C, Pellacani G. In vivo confocal microscopy in clinical practice: comparison of bedside diagnostic accuracy of a trained physician and distant diagnosis of an expert reader. J Am Acad Dermatol 2013 Dec;69(6):e295-300 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24035553.
  8. Guitera P, Pellacani G, Longo C, Seidenari S, Avramidis M, Menzies SW. In vivo reflectance confocal microscopy enhances secondary evaluation of melanocytic lesions. J Invest Dermatol 2009 Jan;129(1):131-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18633444.
  9. Pellacani G, Witkowski A, Cesinaro AM, Losi A, Colombo GL, Campagna A, et al. Cost-benefit of reflectance confocal microscopy in the diagnostic performance of melanoma. J Eur Acad Dermatol Venereol 2015 Oct 7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26446299.
  10. Guitera P, Pellacani G, Crotty KA, Scolyer RA, Li LX, Bassoli S, et al. The impact of in vivo reflectance confocal microscopy on the diagnostic accuracy of lentigo maligna and equivocal pigmented and nonpigmented macules of the face. J Invest Dermatol 2010 Aug;130(8):2080-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20393481.
  11. Menge TD, Hibler BP, Cordova MA, Nehal KS, Rossi AM. Concordance of handheld reflectance confocal microscopy (RCM) with histopathology in the diagnosis of lentigo maligna (LM): A prospective study. J Am Acad Dermatol 2016 Jun;74(6):1114-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26826051.
  12. Borsari S, Pampena R, Lallas A, Kyrgidis A, Moscarella E, Benati E, et al. Clinical Indications for Use of Reflectance Confocal Microscopy for Skin Cancer Diagnosis. JAMA Dermatol 2016 Aug 31 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27580185.
  13. Łudzik J, Witkowski AM, Roterman-Konieczna I, Bassoli S, Farnetani F, Pellacani G. Improving Diagnostic Accuracy of Dermoscopically Equivocal Pink Cutaneous Lesions with Reflectance Confocal Microscopy in Telemedicine Settings: Double Reader Concordance Evaluation of 316 Cases. PLoS One 2016;11(9):e0162495 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27606812.
  14. Guitera P, Menzies SW, Argenziano G, Longo C, Losi A, Drummond M, et al. Dermoscopy and in vivo confocal microscopy are complementary techniques for diagnosis of difficult amelanotic and light-coloured skin lesions. Br J Dermatol 2016 May 13 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27177158.

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