Confocal microscopy of excised human skin using acetic acid and crossed polarization: rapid detection of nonmelanoma skin cancers

Moh's micrographic surgery for basal- and squamous-cell cancers (BCCs, SCCs) involves precise excision of the tumor with minimal damage to the surrounding normal skin. Precise excision is guided by histopathologic examination for tumor margins; typically, 2 - 4 slices of skin are excised, and there is a waiting time of 15 - 45 minutes for the surgeon and patient while each slice is being processed for histopathology. We can avoid the processing by using a confocal reflectance microscope; confocal detection of BCCs and SCCs is possible after staining the nuclei in the excised skin with 5% acetic acid, and imaging in crossed polarization. The cancerous nuclei appear bright against the dark surrounding normal dermis. The contrast is due to increased back-scattering as well as increased depolarization from the intra-nuclear structure relative to that from the surrounding normal dermis. As in conventional histopathology, the tumors are first detected at low resolution (section thickness 20 micrometer) in a wide field (1-2 mm); nuclear morphology is then viewed at high resolution (section thickness 2 micrometer) in a small field (0.25 - 0.50 mm). Mosaics of images are assembled to produce confocal maps of the BCCs or SCCs within large excised tissue. Rapid detection (within minutes) is possible.