Reflectance Confocal Microscopy Enables the Non-invasive Diagnosis and Management of Skin Tumors

  • Salvador González
  • Concepción Parrado
  • Jesús Cuevas


Reflectance-mode confocal microscopy (RCM) is a novel, laser-based technique that enables a non-invasive diagnosis of the skin. Despite a relatively lack of depth, its use is taking off due to its ease of use, reproducibility and lack of invasiveness. Good correlation with the gold standard in diagnosis of skin diseases, which is conventional histology, validates the technique. Recent reports have focused on this crucial aspect for different pathologies as well as non-diseased, physiological skin. Particular attention has been pointed to the diagnosis of different types of cancer, e.g. squamous and basal cell carcinoma and melanoma. In vivo assays have revealed that RCM displays good sensitivity and accuracy for the diagnosis of BCC and melanoma. Furthermore, RCM has also been used to delimit the edges of suspected tumors before surgery and also to image the response of the skin to different treatments. This review summarizes the current state of the art in terms of available RCM units, diagnosis both in vivo and ex vivo and current applications of the technique.


Reflectance-mode confocal microscopy Non-invasive imaging In-vivo microscopy Skin Tumors High-esolution monitoring 


Acknowledgements and Competing Interests

The authors declare no conflict or competing interest.


  1. 1.
    Braun RP, Oliviero M, Kolm I, French LE, Marghoob AA, Rabinovitz H. Dermoscopy: what’s new? Clin Dermatol. 2009;27:26–34.PubMedCrossRefGoogle Scholar
  2. 2.
    Tearney GJ, Brezinski ME, Southern JF, Bouma BE, Hee MR, Fujimoto JG. Determination of the refractive index of highly scattering human tissue by optical coherence tomography. Opt Lett. 1995;20:2258–60.PubMedCrossRefGoogle Scholar
  3. 3.
    Mansotti L. Basic principles and advanced technical aspects of ultrasound imaging. In: Guzzardi R, editor. Physics and engineering of medical imaging. Boston: Martinus Nijhoff; 1987. p. 263–317.CrossRefGoogle Scholar
  4. 4.
    Markisz J, Aquilia M. Technical magnetic resonance imaging. Stanford: Appleton & Lange; 1996.Google Scholar
  5. 5.
    Suihko C, Swindle LD, Thomas SG, Serup J. Fluorescence fibre-optic confocal microscopy of skin in vivo: microscope and fluorophores. Skin Res Technol. 2005;11:254–67.PubMedCrossRefGoogle Scholar
  6. 6.
    Minsky M. Microscopy apparatus. US Patent No 3013467. 1957.Google Scholar
  7. 7.
    Cavanagh HD, Jester JV, Essepian J, Shields W, Lemp MA. Confocal microscopy of the living eye. CLAO J. 1990;16:65–73.PubMedGoogle Scholar
  8. 8.
    Jester JV, Andrews PM, Petroll WM, Lemp MA, Cavanagh HD. In vivo, real-time confocal imaging. J Electron Microsc Tech. 1991;18:50–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Andrews PM, Petroll WM, Cavanagh HD, Jester JV. Tandem scanning confocal microscopy (TSCM) of normal and ischemic living kidneys. Am J Anat. 1991;191:95–102.PubMedCrossRefGoogle Scholar
  10. 10.
    Rajadhyaksha M, Grossman M, Esterowitz D, Webb RH, Anderson RR. In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast. J Invest Dermatol. 1995;104:946–52.PubMedCrossRefGoogle Scholar
  11. 11.
    Rajadhyaksha M. Confocal reflectance microscopy: diagnosis of skin cancer without biopsy? Frontiers of Engineering. Washington, DC: National Academies Press; 1999. p. 24–33.Google Scholar
  12. 12.
    Anderson RR, Parrish JA. The optics of human skin. J Invest Dermatol. 1981;77:13–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Huzaira M, Rius F, Rajadhyaksha M, Anderson RR, Gonzalez S. Topographic variations in normal skin, as viewed by in vivo reflectance confocal microscopy. J Invest Dermatol. 2001;116:846–52.PubMedCrossRefGoogle Scholar
  14. 14.
    Busam KJ, Charles C, Lee G, Halpern AC. Morphologic features of melanocytes, pigmented keratinocytes, and melanophages by in vivo confocal scanning laser microscopy. Mod Pathol. 2001;14:862–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Aghassi D, Anderson RR, Gonzalez S. Confocal laser microscopic imaging of actinic keratoses in vivo: a preliminary report. J Am Acad Dermatol. 2000;43:42–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Horn M, Gerger A, Ahlgrimm-Siess V, Weger W, Koller S, Kerl H, et al. Discrimination of actinic keratoses from normal skin with reflectance mode confocal microscopy. Dermatol Surg. 2008;34:620–5.PubMedGoogle Scholar
  17. 17.
    Ulrich M, Maltusch A, Rius-Diaz F, Rowert-Huber J, Gonzalez S, Sterry W, et al. Clinical applicability of in vivo reflectance confocal microscopy for the diagnosis of actinic keratoses. Dermatol Surg. 2008;34:610–9.PubMedGoogle Scholar
  18. 18.
    Ulrich M, Maltusch A, Rowert-Huber J, Gonzalez S, Sterry W, Stockfleth E, et al. Actinic keratoses: non-invasive diagnosis for field cancerisation. Br J Dermatol. 2007;156 Suppl 3:13–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Al-Arashi M, Salomatina E, Yaroslavsky A. Multimodal confocal microscopy for diagnosing nonmelanoma skin cancers. Lasers Surg Med. 2007;39:696–705.PubMedCrossRefGoogle Scholar
  20. 20.
    Rishpon A, Kim N, Scope A, Porges L, Oliviero MC, Braun RP, et al. Reflectance confocal microscopy criteria for squamous cell carcinomas and actinic keratoses. Arch Dermatol. 2009;145:766–72.PubMedCrossRefGoogle Scholar
  21. 21.
    Gonzalez S, Tannous Z. Real-time, in vivo confocal reflectance microscopy of basal cell carcinoma. J Am Acad Dermatol. 2002;47:869–74.PubMedCrossRefGoogle Scholar
  22. 22.
    Nori S, Rius-Diaz F, Cuevas J, Goldgeier M, Jaen P, Torres A, et al. Sensitivity and specificity of reflectance-mode confocal microscopy for in vivo diagnosis of basal cell carcinoma: a multicenter study. J Am Acad Dermatol. 2004;51:923–30.PubMedCrossRefGoogle Scholar
  23. 23.
    Guitera P, Menzies SW, Longo C, Cesinaro AM, Scolyer RA, Pellacani G. In vivo confocal microscopy for diagnosis of melanoma and basal cell carcinoma using a two-step method: analysis of 710 consecutive clinically equivocal cases. J Invest Dermatol. 2012;132:2386–94.PubMedCrossRefGoogle Scholar
  24. 24.
    Agero AL, Gill M, Ardigo M, Myskowski P, Halpern AC, González S. In vivo reflectance confocal microscopy of mycosis fungoides: a preliminary study. J Am Acad Dermatol. 2007;57:435–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Lange-Asschenfeldt S, Babilli J, Beyer M, Rius-Diaz F, Gonzalez S, Stockfleth E, et al. Consistency and distribution of reflectance confocal microscopy features for diagnosis of cutaneous T cell lymphoma. J Biomed Opt. 2012;17:016001.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Scope A, Ardigo M, Marghoob AA. Correlation of dermoscopic globule-like structures of dermatofibroma using reflectance confocal microscopy. Dermatology. 2008;216:81–2.PubMedCrossRefGoogle Scholar
  27. 27.
    Agero AL, Busam KJ, Benvenuto-Andrade C, Scope A, Gill M, Marghoob AA, et al. Reflectance confocal microscopy of pigmented basal cell carcinoma. J Am Acad Dermatol. 2006;54:638–43.PubMedCrossRefGoogle Scholar
  28. 28.
    Segura S, Puig S, Carrera C, Palou J, Malvehy J. Dendritic cells in pigmented basal cell carcinoma: a relevant finding by reflectance-mode confocal microscopy. Arch Dermatol. 2007;143:883–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Langley RG, Rajadhyaksha M, Dwyer PJ, Sober AJ, Flotte TJ, Anderson RR. Confocal scanning laser microscopy of benign and malignant melanocytic skin lesions in vivo. J Am Acad Dermatol. 2001;45:365–76.PubMedCrossRefGoogle Scholar
  30. 30.
    Pellacani G, Cesinaro AM, Longo C, Grana C, Seidenari S. Microscopic in vivo description of cellular architecture of dermoscopic pigment network in nevi and melanomas. Arch Dermatol. 2005;141:147–54.PubMedCrossRefGoogle Scholar
  31. 31.
    Pellacani G, Cesinaro AM, Seidenari S. In vivo assessment of melanocytic nests in nevi and melanomas by reflectance confocal microscopy. Mod Pathol. 2005;18:469–74.PubMedCrossRefGoogle Scholar
  32. 32.
    Pellacani G, Farnetani F, Gonzalez S, Longo C, Cesinaro AM, Casari A, et al. In vivo confocal microscopy for detection and grading of dysplastic nevi: a pilot study. J Am Acad Dermatol. 2012;66:e109–21.PubMedCrossRefGoogle Scholar
  33. 33.
    Shoo BA, Sagebiel RW, Kashani-Sabet M. Discordance in the histopathologic diagnosis of melanoma at a melanoma referral center. J Am Acad Dermatol. 2010;62:751–6.PubMedCrossRefGoogle Scholar
  34. 34.
    McGovern VJ, Mihm Jr MC, Bailly C, Booth JC, Clark Jr WH, Cochran AJ, et al. The classification of malignant melanoma and its histologic reporting. Cancer. 1973;32:1446–57.PubMedCrossRefGoogle Scholar
  35. 35.
    Clark Jr WH, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res. 1969;29:705–27.PubMedGoogle Scholar
  36. 36.
    Pellacani G, Cesinaro AM, Seidenari S. Reflectance-mode confocal microscopy of pigmented skin lesions–improvement in melanoma diagnostic specificity. J Am Acad Dermatol. 2005;53:979–85.PubMedCrossRefGoogle Scholar
  37. 37.
    Pellacani G, Guitera P, Longo C, Avramidis M, Seidenari S, Menzies S. The impact of in vivo reflectance confocal microscopy for the diagnostic accuracy of melanoma and equivocal melanocytic lesions. J Invest Dermatol. 2007;127:2759–65.PubMedGoogle Scholar
  38. 38.
    Hashemi P, Pulitzer MP, Scope A, Kovalyshyn I, Halpern AC, Marghoob AA. Langerhans cells and melanocytes share similar morphologic features under in vivo reflectance confocal microscopy: a challenge for melanoma diagnosis. J Am Acad Dermatol. 2012;66:452–62.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Segura S, Pellacani G, Puig S, Longo C, Bassoli S, Guitera P, et al. In vivo microscopic features of nodular melanomas: dermoscopy, confocal microscopy, and histopathologic correlates. Arch Dermatol. 2008;144:1311–20.PubMedCrossRefGoogle Scholar
  40. 40.
    Ahlgrimm-Siess V, Massone C, Scope A, Fink-Puches R, Richtig E, Wolf IH, et al. Reflectance confocal microscopy of facial lentigo maligna and lentigo maligna melanoma: a preliminary study. Br J Dermatol. 2009;161:1307–16.PubMedCrossRefGoogle Scholar
  41. 41.
    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;130:2080–91.PubMedCrossRefGoogle Scholar
  42. 42.
    Busam KJ, Hester K, Charles C, Sachs DL, Antonescu CR, Gonzalez S, et al. Detection of clinically amelanotic malignant melanoma and assessment of its margins by in vivo confocal scanning laser microscopy. Arch Dermatol. 2001;137:923–9.PubMedGoogle Scholar
  43. 43.
    Pellacani G, Vinceti M, Bassoli S, Braun R, Gonzalez S, Guitera P, et al. Reflectance confocal microscopy and features of melanocytic lesions: an internet-based study of the reproducibility of terminology. Arch Dermatol. 2009;145:1137–43.PubMedCrossRefGoogle Scholar
  44. 44.
    Curiel-Lewandrowski C, Williams CM, Swindells KJ, Tahan SR, Astner S, Frankenthaler RA, et al. Use of in vivo confocal microscopy in malignant melanoma: an aid in diagnosis and assessment of surgical and nonsurgical therapeutic approaches. Arch Dermatol. 2004;140:1127–32.PubMedCrossRefGoogle Scholar
  45. 45.
    Rajadhyaksha M, Menaker G, Flotte T, Dwyer PJ, Gonzalez S. Confocal examination of nonmelanoma cancers in thick skin excisions to potentially guide mohs micrographic surgery without frozen histopathology. J Invest Dermatol. 2001;117:1137–43.PubMedCrossRefGoogle Scholar
  46. 46.
    Chung VQ, Dwyer PJ, Nehal KS, Rajadhyaksha M, Menaker GM, Charles C, et al. Use of ex vivo confocal scanning laser microscopy during Mohs surgery for nonmelanoma skin cancers. Dermatol Surg. 2004;30:1470–8.PubMedGoogle Scholar
  47. 47.
    Karen JK, Gareau DS, Dusza SW, Tudisco M, Rajadhyaksha M, Nehal KS. Detection of basal cell carcinomas in Mohs excisions with fluorescence confocal mosaicing microscopy. Br J Dermatol. 2009;160:1242–50.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Gareau DS, Patel YG, Li Y, Aranda I, Halpern AC, Nehal KS, et al. Confocal mosaicing microscopy in skin excisions: a demonstration of rapid surgical pathology. J Microsc. 2009;233:149–59.PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Goldgeier M, Fox CA, Zavislan JM, Harris D, Gonzalez S. Noninvasive imaging, treatment, and microscopic confirmation of clearance of basal cell carcinoma. Dermatol Surg. 2003;29:205–10.PubMedGoogle Scholar
  50. 50.
    Torres A, Niemeyer A, Berkes B, Marra D, Schanbacher C, Gonzalez S, et al. 5% imiquimod cream and reflectance-mode confocal microscopy as adjunct modalities to Mohs micrographic surgery for treatment of basal cell carcinoma. Dermatol Surg. 2004;30:1462–9.PubMedGoogle Scholar
  51. 51.
    Longo C, Casari A, Pepe P, Moscarella E, Zalaudek I, Argenziano G, et al. Confocal microscopy insights into the treatment and cellular immune response of basal cell carcinoma to photodynamic therapy. Dermatology. 2012;225:264–70.PubMedCrossRefGoogle Scholar
  52. 52.
    Ahlgrimm-Siess V, Horn M, Koller S, Ludwig R, Gerger A, Hofmann-Wellenhof R. Monitoring efficacy of cryotherapy for superficial basal cell carcinomas with in vivo reflectance confocal microscopy: a preliminary study. J Dermatol Sci. 2009;53:60–4.PubMedCrossRefGoogle Scholar
  53. 53.
    Venturini M, Sala R, Gonzalez S, Calzavara-Pinton PG. Reflectance confocal microscopy allows in vivo real-time noninvasive assessment of the outcome of methyl aminolaevulinate photodynamic therapy of basal cell carcinoma. Br J Dermatol. 2013;168:99–105.PubMedCrossRefGoogle Scholar
  54. 54.
    Bencini PL, Tourlaki A, Galimberti M, Longo C, Pellacani G, De Giorgi V, et al. Nonablative fractional photothermolysis for acne scars: clinical and in vivo microscopic documentation of treatment efficacy. Dermatol Ther. 2012;25:463–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Shin MK, Kim MJ, Baek JH, Yoo MA, Koh JS, Lee SJ, et al. Analysis of the temporal change in biophysical parameters after fractional laser treatments using reflectance confocal microscopy. Skin Res Technol. 2013;19:e515–20.PubMedCrossRefGoogle Scholar
  56. 56.
    Longo C, Galimberti M, De Pace B, Pellacani G, Bencini PL. Laser skin rejuvenation: epidermal changes and collagen remodeling evaluated by in vivo confocal microscopy. Lasers Med Sci. 2013;28:769–76.PubMedCrossRefGoogle Scholar
  57. 57.
    Vano-Galvan S, Fernandez-Lizarbe E, Truchuelo M, Diaz-Ley B, Grillo E, Sanchez V, et al. Dynamic skin changes of acute radiation dermatitis revealed by in vivo reflectance confocal microscopy. J Eur Acad Dermatol Venereol. 2012. doi: 10.1111/j.1468-3083.2012.04680.x.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  • Salvador González
    • 1
  • Concepción Parrado
    • 2
  • Jesús Cuevas
    • 3
  1. 1.Dermatology ServiceRamon y Cajal Hospital (Consultant), Memorial Sloan-Kettering Cancer CenterNew YorkUSA
  2. 2.Department of Histology and PathologyUniversity of Málaga, Campus de TeatinosMalagaSpain
  3. 3.Pathology DepartmentGuadalajara University Hospital, University of AlcaláAlcalá de Henares (Madrid)Spain

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