The role of reflectance confocal microscopy in differentiating melanoma in situ from dysplastic nevi with severe atypia: A cross-sectional study

Background: Melanoma in situ and dysplastic nevi with severe atypia present overlapping histopathologic features. Reflectance confocal microscopy findings can be integrated with the dermatopathology report to improve differentiation between melanoma and dysplastic nevi with severe atypia. Objective: To compare prevalence of reflectance confocal microscopy findings between melanoma in situ and dysplastic nevi with severe atypia. Methods: This retrospective observational study compared reflectance confocal microscopy findings in dermatopathologically diagnosed dysplastic nevi with severe atypia and melanoma in situ, collected between 2007 and 2017 at a private pigmented-lesion clinic. Concordant pathologic diagnosis was defined as unanimous agreement between 3 dermatopathologists who independently reviewed all cases; all other cases were classified as discordant. Results: The study included 112 lesions, 62 concordant melanomas in situ, 28 concordant dysplastic nevi with severe atypia, and 22 discordant lesions. In comparing reflectance confocal microscopy findings in concordant cases, melanoma in situ showed more frequently than dysplastic nevi with severe atypia the presence of epidermal atypical melanocytes as round cells (19/62 vs 0/28; P <.001) and dendritic cells (50/62 vs 6/28; P <.001), as well as a diffuse distribution of epidermal atypical melanocytes (50/54 vs 3/6; P =.002). In contrast, dysplastic nevi with severe atypia showed the presence of dense melanocytic nests more frequently than melanoma in situ did (15/28 vs 14/62; P =.003). Limitations: The study was based on a limited number of lesions originating from a single clinic. Conclusions: Reflectance confocal microscopy findings may help differentiate a subset of dysplastic nevi with severe atypia from melanoma in situ.