Peri-operative imaging of cancer margins with reflectance confocal microscopy during Mohs micrographic surgery: feasibility of a video-mosaicing algorithm

Abstract

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.