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Reflectance confocal microscopy (RCM) imaging shows promise for guiding surgical treatment of skin cancers. Recent
technological advancements such as the introduction of the handheld version of the reflectance confocal microscope,
video acquisition and video-mosaicing have improved RCM as an emerging tool to evaluate cancer margins during
routine surgical skin procedures such as Mohs micrographic surgery (MMS). Detection of residual non-melanoma skin
cancer (NMSC) tumor during MMS is feasible, as demonstrated by the introduction of real-time perioperative imaging
on patients in the surgical setting. Our study is currently testing the feasibility of a new mosaicing algorithm for perioperative
RCM imaging of NMSC cancer margins on patients during MMS. We report progress toward imaging and
image analysis on forty-five patients, who presented for MMS at the MSKCC Dermatology service. The first 10 patients
were used as a training set to establish an RCM imaging algorithm, which was implemented on the remaining test set of
35 patients. RCM imaging, using 35% AlCl3 for nuclear contrast, was performed pre- and intra-operatively with the
Vivascope 3000 (Caliber ID). Imaging was performed in quadrants in the wound, to simulate the Mohs surgeon’s
examination of pathology. Videos were taken at the epidermal and deep dermal margins. Our Mohs surgeons assessed
all videos and video-mosaics for quality and correlation to histology. Overall, our RCM video-mosaicing algorithm is
feasible. RCM videos and video-mosaics of the epidermal and dermal margins were found to be of clinically acceptable
quality. Assessment of cancer margins was affected by type of NMSC, size and location. Among the test set of 35
patients, 83% showed acceptable imaging quality, resolution and contrast. Visualization of nuclear and cellular
morphology of residual BCC/SCC tumor and normal skin features could be detected in the peripheral and deep dermal
margins. We observed correlation between the RCM videos/video-mosaics and the corresponding histology in 32
lesions. Peri-operative RCM imaging shows promise for improved and faster detection of cancer margins and guiding
MMS in the surgical setting.
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