In vivo Reflectance Confocal Microscopy
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This tutorial is provided to describe the unifying concept of confocal microscopy with complete definitions of the parameters and example images. Afer completion, please proceed to the training area, where a set with 45 images is available for the refinement and final elaboration of the list. All tutorial set images cover an area of 470x350 μm.
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RCM features description

Basal Cell Layer and Dermal-Epidermal Junction

By means of RCM, basal cells appear at a depth of approximately 50 to 100 μm below the stratum corneum. Going in depth, dermal papillae correspond to dark round to oval areas circumscribed by refractive cells, corresponding to melanocytes and melanin-rich keratinocytes.

Papillary contour features

Edged papillae correspond to dermal papillae circumscribed by a rim of refractive cells, appearing as bright rings sharply contrasting with the dark background (Fig. 24,25).

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Figure 24. Edged papillae, with typical cells

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Figure 25. Edged papillae, with typical cells

Non edged papillae are reported for the observation of dermal papillae without a demarcated rim of bright cells, but separated by a series of large reflecting cells (Fig. 27,29).

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Figure 27. Non edged papillae, with typical cells

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Figure 29. Non edged papillae, with few atypical brighter cells (mild atypia)

Junctional nest features

The presence of clusters of reflecting cells corresponding to junctional melanocytic nests, is described.

Junctional clusters are oval compact cellular aggregates bulging within the dermal papilla, directly in connection with the basal cell layer (Fig. 30-32).

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Figure 30. Junctional cluster

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Figure 31. Junctional cluster

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Figure 32. Junctional cluster

Junctional thickenings are enlargements of the inter-papillary space formed by aggregated cells (Fig. 33-35).

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Figure 33. Junctional thickening

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Figure 34. Junctional thickening

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Figure 35. Junctional thickening

Cellular aspects

The presence of cellular atypia in basal layer (outside the nests) is considered. Cells are morphologically described considering cytological atypia throughout the lesion.

Cellular atypia grade

Typical cells correspond to mono-morphous small cell (Fig. 24-28).

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Figure 24. Edged papillae, with typical cells

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Figure 25. Edged papillae, with typical cells

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Figure 26. Edged papillae, with typical cells

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Figure 27. Non edged papillae, with typical cells

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Figure 28. Non edged papillae, with typical cells

Mild atypia is considered when irregular larger cells are sporadically observable within typical cell architecture (Fig. 37,38).

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Figure 37. Mild atypia, and non edged papillae

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Figure 38. Mild atypia, and non edged papillae

Marked atypia is considered when numerous cells irregular in size, shape and reflectivity, round to oval or stellate, occasionally with branching dendritic-like structures, are distributed throughout the lesion (Fig. 39,40).

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Figure 39. Marked atypia, and non edged papillae

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Figure 40. Marked atypia, and non edged papillae

Cells distributed in sheet-like structures

It corresponds to cells in the transition of the epidermis and dermis not aggregated in clusters but closely distributed in the same plane. Dermal papillae are not distinguishable due to the lost of normal rete ridge pattern. These cells are exhibiting a hyperrefractive cytoplasm (compared to the surrounding tissue that they infiltrate). They may present a roundish more or less regular shape or a spindle morphology oriented in the same direction.

Cells can be defined as:

Non Pleomorphic, characterized by each other similar cells (Fig. 41,42), Pleomorphic, constituted by atypical and dishomogeneous cells (Fig. 43,44), and Spindled, formed by elongated pleomorphic cells oriented toward the same direction (Fig. 45,46).

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Figure 41. Cells distributed in sheet like structures (non visible papillae), with non pleomorphic cells

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Figure 42. Cells distributed in sheet like structures (non visible papillae), with non pleomorphic cells

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Figure 43. Cells distributed in sheet like structures (non visible papillae), with pleomorphic cells (and marked atypia)

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Figure 44. Cells distributed in sheet like structures (non visible papillae), with pleomorphic cells (and marked atypia)

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Figure 45. Cells distributed in sheet like structures (non visible papillae), with spindled cells (and marked atypia)

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Figure 46. Cells distributed in sheet like structures (non visible papillae), with spindled cells (and marked atypia)

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