JMIR Publications

ABSTRACT

Background:

Reflectance confocal microscopy (RCM) is a non-invasive tool that is used to diagnose skin cancers. However, RCM requires an expert consultation, which is often performed via store-and-forward (SAF) teledermatology. Unfortunately, SAF does not mimic bedside diagnosis, nor permits interaction between the remote-expert reader, physician, and patient. Recently, a live-interactive method (LIM)–tele–RCM approach was demonstrated to diagnose BCC from a remote location, demonstrated advantages over SAF by providing a bedside diagnosis during consultation.

Objective:

To validate (LIM)–tele–RCM approach to diagnose BCC in a real-world setting.

Methods:

In this pilot study, four patients with six clinically suspicious BCCs lesions were enrolled and imaged with RCM at a Los Angeles dermatology clinic. A HIPAA-compliant teleconferencing application was used to live stream RCM images to an expert RCM reader in New York. The expert reader had remote control of the software, direct audio communication with the clinic, and patient’s clinical history with dermoscopy. During imaging, RCM features were noted, and a diagnosis was made at the bedside. After imaging, patients completed a short questionnaire (on a 1-5 scale, 5 being the highest score) about satisfaction, comfort, and communication during the session.

Results:

RCM diagnosed 4/6 (66.7%) lesions correctly as BCC and 2/6 (33.3%) were false-positive. The true-positive lesions had “tumor islands with palisading and clefting” and were directly managed with Mohs surgery. The false-positive lesions had “dark silhouettes” (a common false-positive feature for BCC) and underwent a shave biopsy for confirmation. The entire session ranged from 15-20 minutes (average of 17.7 minutes), comparable to reported RCM procedure time. Results are summarized in Multimedia Appendix 1. On the questionnaire, all patients responded with the highest rating (5/5) for each question.

Conclusions:

LIM–tele–RCM demonstrates potential advantages over the SAF method, enabling bedside diagnosis with similar diagnostic accuracy as reported in the literature and correct management. Additionally, the remote reader had access to clinical background and could engage with patients. It may also be useful for training novice RCM users and beneficial in settings where remote diagnostics are desired, such as during the recent COVID-19 pandemic. However, technical challenges such as image quality degradation during video streaming, poor internet bandwidth, and end-user latency may impact diagnosis. Larger, multi-center studies are needed to assess the accuracy of LIM–tele–RCM for the diagnosis of BCC and other neoplastic and inflammatory lesions, and to quantify technical limitations.