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Journal of the American Academy of Dermatology
Sous presse. Epreuves corrigées par l'auteur. Disponible en ligne depuis le vendredi 31 janvier 2020
Doi : 10.1016/j.jaad.2019.05.101
accepted : 23 May 2019
Improvement of diagnostic confidence and management of equivocal skin lesions by integration of reflectance confocal microscopy in daily practice: Prospective study in 2 referral skin cancer centers

Oriol Yélamos, MD a, b, , Elena Manubens, MD b, Manu Jain, MD a, Marion Chavez-Bourgeois, MD b, Sri V. Pulijal, MD a, Stephen W. Dusza, DrPH a, Michael A. Marchetti, MD a, Alicia Barreiro, MD b, Maria L. Marino, MD a, Josep Malvehy, MD, PhD b, c, Miguel A. Cordova, MD a, Anthony M. Rossi, MD a, Milind Rajadhyaksha, PhD a, Allan C. Halpern, MD, MSc a, Susana Puig, MD, PhD b, c, Ashfaq A. Marghoob, MD a, Cristina Carrera, MD, PhD a, b, c,
a Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York 
b Dermatology Department, Melanoma Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain 
c Centro de Investigación en Red en Enfermedades Raras (CIBERER) Instituto Carlos III, Barcelona, Spain 

Correspondence to: Cristina Carrera, MD, PhD, Dermatology Department, Hospital Clínic de Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain.Dermatology DepartmentHospital Clínic de BarcelonaCarrer Villarroel 170Barcelona08036SpainOriol Yélamos, MD, Dermatology Department, Hospital Clınic de Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain.Dermatology Department, Hospital Clınic de BarcelonaCarrer Villarroel 170Barcelona08036Spain

Reflectance confocal microscopy (RCM) allows accurate, noninvasive, in vivo diagnosis for skin cancer. However, its impact on physicians' diagnostic confidence and management is unknown.


We sought to assess the physicians' diagnostic confidence and management before and after RCM of equivocal skin lesions.


Prospective, 2-center, observational study. During clinical practice, 7 dermatologists recorded their diagnostic confidence level (measured in a scale from 0 to 10), diagnosis, and management before and after RCM of clinically/dermoscopically equivocal lesions that raised concern for skin cancer. We also evaluated the diagnostic accuracy before and after RCM.


We included 272 consecutive lesions from 226 individuals (mean age, 53.5 years). Diagnostic confidence increased from 6.2 to 8.1 after RCM (P  < .001) when RCM confirmed or changed the diagnosis. Lesion management changed in 33.5% cases after RCM (to observation in 51 cases and to biopsy/excision in 31 cases). After RCM, the number needed to excise was 1.2. Sensitivity for malignancy before and after RCM was 78.2% and 85.1%, respectively. Specificity before and after RCM was 78.8% and 80%, respectively.


Small sample size, real-life environment, and different levels of expertise among RCM users.


Physicians' diagnostic confidence and accuracy increased after RCM when evaluating equivocal tumors, frequently resulting in management changes while maintaining high diagnostic accuracy.

The full text of this article is available in PDF format.

Key words : basal cell carcinoma, diagnostic accuracy, diagnostic confidence level, management, melanoma, reflectance confocal microscopy, skin cancer

Abbreviations used : BCC, NNE, RCM, SCC, SD

 Funding sources: Supported in part by the National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748 and personal grants to Dr Yélamos (by Beca Fundación Piel Sana) and Dr Carrera (by Hospital Clínic Barcelona for foreign research stay). Research and confocal imaging in the Melanoma Unit in Barcelona is partly funded by the Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Raras of the Instituto de Salud Carlos III, Spain, cofinanced by European Development Regional Fund “A way to achieve Europe” European Regional Development Fund (ERDF) and by the European Commission under the 7th Framework Programme (Diagnoptics).
 Disclosure: Dr Rajadhyaksha is a former employee of and owns equity in Caliber Imaging and Diagnostics (formerly Lucid Inc), the company that manufactures and sells the Vivascope confocal microscope. The Vivascope is the commercial version of an original laboratory prototype that he developed at Massachusetts General Hospital, Harvard Medical School. Drs Yélamos, Manubens, Jain, Chavez-Bourgeois, Pulijal, Dusza, Marchetti, Barreiro, Marino, Malvehy, Cordova, Rossi, Halpern, Puig, Marghoob, and Carrera have no conflicts of interest to declare.
 Reprints not available from the authors.

© 2019  American Academy of Dermatology, Inc.@@#104156@@
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