Noninvasive Diagnosis of Non-melanoma Skin Cancer: Focus on Reflectance Confocal Microscopy

Martina Ulrich; Susanne Astner; Eggert Stockfleth; Joachim Röwert-Huber


Expert Rev Dermatol. 2008;3(5):557-567. 

In This Article

Abstract and Introduction


Non-melanoma skin cancer (NMSC) represents the most common cutaneous neoplasms and, in the past decade, nonsurgical treatment modalities have been established as part of the management of NMSC. Recently, novel noninvasive diagnostic modalities have been developed and, of these, reflectance confocal microscopy (RCM) offers imaging of the skin in vivo with cellular resolution. NMSCs, including basal cell carcinoma, actinic keratosis and squamous cell carcinoma, have been evaluated by RCM, and diagnostic criteria were defined. By correlation with routine histology sections and in comparison with normal skin, RCM showed high sensitivity and specificity values. RCM allows the noninvasive evaluation of a variety of skin conditions, including NMSC. RCM may aid in the diagnosis and differential diagnosis of NMSC, as well as in monitoring of treatment response to topical treatment modalities. Therefore, RCM appears to be a promising diagnostic tool with many possible applications in dermatology.


The differential diagnosis of inflammatory and neoplastic skin disorders may often be obtained based on clinical examination, since abnormal skin findings are readily amenable to visual inspection. However, the differential diagnosis may be broad and biopsy with subsequent histology is often performed for confirmation. Therefore, histology remains the current diagnostic 'gold standard' in dermatology. Skin cancer biopsies are routinely performed for accurate diagnostic classification and optimized tumor management.

However, skin biopsies may be associated with significant disadvantages as the procedure itself is invasive, thereby leading to pain and scar formation. Histological processing and staining induce irreversible tissue alterations and may ultimately result in artefacts. A histological evaluation per-definition precludes an in vivo examination and does not permit repeated evaluations over time. Following initial diagnosis by biopsy, a second surgical procedure is often required for complete removal of the lesion.

In the past decades, a number of adjunct diagnostic techniques have been introduced in dermatology, including, among others, dermoscopy, high-frequency ultrasound and optical coherence tomography. These modalities allow the noninvasive evaluation of skin with differences in penetration depth and resolution, but do not visualize cellular details. Recently, reflectance confocal microscopy (RCM) has been evaluated for a variety of inflammatory and neoplastic skin conditions. In contrast to other noninvasive imaging techniques, RCM allows the assessment of cellular details and microstructures of the skin with a resolution comparable to routine histology sections. Herein, we present an overview of RCM with special regard to non-melanoma skin cancer (NMSC).


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