Skin Research and Technology 2013; 19: 352–355
Printed in Singapore
All rights reserved
doi: 10.1111/srt.12049
Short Report
Reflectance confocal microscopy for the characterization
of mycosis fungoides and correlation with histology: a
pilot study
Wei Li, Hui Dai, Zhao Li and Ai-E Xu
Department of Dermatology, Affiliated Hangzhou Clinical College, Anhui Medical University, Hangzhou, China
Background: Mycosis fungoides (MF) is cutaneous lymphoma
of the T-cell lineage. MF is a diagnostic challenge. In vivo
reflectance confocal microscopy (RCM) reproducible imaging
technique already reported to be useful in the diagnosis of skin
diseases. The aims of our study were to define RCM features
of MF and to evaluate its feasibility in biopsy site selection.
Methods: Each lesion was selected for RCM evaluation from
10 patients with an established diagnosis of MF. Subsequently,
a biopsy of the same areas evaluated with RCM was rendered
for histopathological examination.
Results: A series of RCM features of MF was identified and
shown to correlate well with histopathological evaluation. We
could find hyperkeratosis in five patients (10 : 50%); disarray
of honeycomb of stratum spinosum in three patients
(10 : 30%). In 10 patients (10 : 100%) of the MF, we could
find that dermal papillary rings were weak reflected light; round
(MF) represent the most
M YCOSIS FUNGOIDES
common of cutaneous T-cell lymphomas.
The disease starts with non-specific scaly
lesions resembling chronic dermatitis, parapso-
riasis, tinea corporis or other inflammatory der-
matoses (1). At present, the histopathology and
immunohistochemistry is still the gold standard
for diagnosis of MF.
In vivo reflectance confocal microscopy (RCM)
is a new tool. The ability to evaluate a skin
lesion microscopically in a non-invasive and
real-time fashion has long been a goal for der-
matologists and dermatopathologists (2). This
study was designed to study the diagnostic
applicability of RCM for MF. In this study, we
recruited some cases with suspected lesions of
MF to identify RCM features, and to correlate
them with histopathological findings of biopsy
specimens obtained from the same lesions.
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© 2013 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
Skin Research and Technology
to oval cells diffusely widespread throughout the epidermis and
in the papillary dermis, infiltration of inflammatory cells in
superficial dermis. Two (10 : 20%) of them can find vesicle
area opaca in plaque stage MF, filled with monomorphous
weakly refractile oval to round cells.
Conclusion: The utility of RCM as a diagnostic tool for MF
awaits further evaluation, although it appears to be promising
for biopsy site selection.
Key words: reflectance confocal microscopy – mycosis
fungoides – histopathology
Ó 2013 John Wiley & Sons A/S. Published by John
Wiley & Sons Ltd
Accepted for publication 6 January 2013
Materials and Methods
Subjects
Ten patients were recruited prospectively
over a period of 11 months. Ten patients
included four women and six men, age rang-
ing from 7 to 77 year and the duration was
1–5 year. Each lesion was selected for RCM
evaluation from 10 patients with an estab-
lished diagnosis of MF. All patients provided
informed consent for examination of their
lesions by RCM and biopsy. These 10 lesions
were confirmed to be MF by histopathology:
patch stage (n = 3), plaque stage (n = 5) and
tumor stage (n = 2). Consent was obtained
prior to enrollment and all clinical investiga-
tion was conducted according to the institu-
tional rules governing clinical investigation of
human subjects.
 RCM features of MF

In vivo RCM (a)

A commercially available in vivo RCM device
(Vivascope 1500; Lucid Inc., Rochester, NY,
USA) was used for imaging. The instrument
operates with a diode laser at an 830 nm
wavelength and a laser power <35 mW at tis-
sue level. This system provides high-resolution
images (approximately 1–2 lm in the lateral
dimension and 4–5 lm in the axial ones) to a
depth of 200–350 lm in vivo (from the epider-
mis down to the superficial reticular dermis).
A 309 water-immersion objective lens with a
numerical aperture of 0.9 with water (refractive
index, 1.33) as an immersion medium was
used. (b)
We obtained 0.5 9 0.5 mm images of indi-
vidual en face optical sections of the involved
skin lesions throughout the skin layers. For
each case, five captures (of stratum corneum,
stratum granulosum, stratum spinosum,
dermoepidermal junction and of the papillary
dermis zone) and one representative stack (16
captures at intervals of 5 lm, starting from
stratum corneum to upper dermis) were
preselected.

Histopathology
Those 10 patients with typical MF lesions were (c)
biopsied. A biopsy was taken from lesional skin
of each patient at the same site where the RCM
examination was performed for histopathologic
analysis. The tissue was fixed in formalin and
embedded in paraffin. After routine processing,
five-micrometer thick sections were stained
with hematoxylin-eosin; molecular studies and
immunohistochemical were also performed as
necessary.

Results Fig. 1. (a) Reflectance confocal microscopy (RCM) imaging of patch

MF, patch stage
Reflectance confocal microscopy features: disar-
ray of honeycomb of stratum spinosum, dermal
papillary rings were weak reflected light
(Fig. 1a), round to oval cells diffusely wide-
spread throughout the epidermis and in the
papillary dermis, infiltration of inflammatory
cells in superficial dermis (Fig. 1b).
Histopathology findings: sparse lymphocytic
infiltrate with lymphocytes lined up along the
junctional zone and scattered throughout the
epidermis (Fig. 1c).
type mycosis fungoides: dermal papillary rings were weak reflected
light. (b) round to oval cells diffusely widespread throughout the
epidermis. (c) Histologic findings of patch type mycosis fungoides.
MF, plaque stage
Reflectance confocal microscopy features:
hyperkeratosis, dermal papillary rings were
weak reflected light, round to oval cells dif-
fusely widespread throughout the epidermis
and in the papillary dermis, infiltration of
inflammatory cells in superficial dermis
(Fig. 2a). Two of them can find vesicle area

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Li et al.

(a)
Fig. 2. (a) Reflectance confocal microscopy (RCM) imaging of
plaque type mycosis fungoides: infiltration of inflammatory cells in
superificial dermis. (b) vesicle area opaca, filled with monomorphous
weakly refractile oval to round cells. (c) vesicle area opaca, filled with
monomorphous weakly refractile oval to round cells. (d) Histologic
findings of plaque type mycosis fungoides.

opaca, filled with monomorphous weakly

refractile oval to round cells (Fig. 2b and c).
Histopathology findings: epidermotropism of
lymphocytes forming Pautrier microabscesses
(Fig. 2d).

MF, tumor stage

(b) Reflectance confocal microscopy features: der-
mal papillary rings were weak reflected light,
roundish and large pleomorphic cells diffusely
widespread throughout the epidermis and in
the papillary dermis (Fig. 3a).
Histopathology findings: medium-sized to
large atypical lymphocytes with pleomorphic
nuclei and abundant cytoplasm (Fig. 3b).

(a)

(c)

(b)

(d)

Fig. 3. (a) Reflectance confocal microscopy (RCM) imaging of tumor

type mycosis fungoides: roundish and large pleomorph cells diffusely
widespread throughout the epidermis and in the papillary dermis. (b)
Histologic findings of tumor type mycosis fungoides.

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 RCM features of MF

histopathology. In tumor stage of MF, roundish

Discussion
Mycosis fungoides belong to the subgroup of
cutaneous malignant T-cell lymphoma (3). It is
clinically divided into three stages: patch, pla-
que and tumor stage. Since the clinical manifes-
tations of MF are complicated and varied, its
diagnosis is difficult. RCM represents a non-
invasive, less painful and non-destructive tissue
method. The skin is unaffected during prepar-
ing procedures, thus minimizing the artifacts
(4).RCM offers the opportunity for improving
the disadvantages of biopsy and histopathology
analysis.
In this study, we could find that dermal pap-
illary rings were weak reflected light, we think
this may be caused by infiltration of atypical
lymphocytes from the lower stratosphere.
Round to oval cells diffusely widespread
throughout the epidermis, this is consistent
with other reports (5, 6). In addition, highly
refractile inflammatory cells can be seen within
the papillary dermis in the lesional skin, a limi-
tation of RCM examination besides imaging
depth was the inability to distinguish lympho-
cytes from other inflammatory cells. Two of
them can find vesicle area opaca in plaque stage
MF, filled with monomorphous weakly refrac-
tile oval to round cells at the granular-spinous
layers. We consider that these structures
corresponded to Pautrier’s microabscesses on
and large pleomorphic cells diffusely wide-
spread throughout the epidermis and in the
papillary dermis may be used for description of
what most likely corresponds to atypical lym-
phocytes in routine histology. We presumed
that this phenomenon has good specificity in
the diagnosis of MF by using RCM. However,
we needed a limited number of patients to vali-
date the present result studies on larger num-
bers of MF cases. Several RCM features were
identified, showing good agreement with histo-
pathology, it can be used as non-invasive diag-
nostic techniques for MF. It allows repetitive
sampling without biopsy collection, so we can
choose the skin lesions image with epidermo-
tropic lymphocytes, to guide optimal biopsy
collection, then it can greatly improve the histo-
pathologic diagnose rate of MF.
In conclusion, RCM is a new imaging tool in
dermatology. Our study is a descriptive, involv-
ing a limited number of patients. Further RCM
studies on larger numbers of MF cases are
needed to validate the present results. And
other limitation on RCM include imaging
depth, RCM did not visualize dermal infiltra-
tion by tumor cells in tumor-stage MF. Thus,
the utility of RCM as a diagnostic tool for MF
awaits further evaluation, although it appears
to be promising for biopsy site selection.

References
1. Susanne LA, Jasmin B, Marc B,
Francisca RD, Salvador G, Eggert S,
Martina U. Consistency and distri-
bution of reflectance confocal
microscopy features for diagnosis of
cutaneous T cell lymphoma. J Bio-
med Opt 2012; 17: 016001–016007.
2. Gonzalez S, Gilaberte-Calzada Y. In
vivo reflectance-mode confocal
microscopy in clinical dermatology
and cosmetology. Int J Cosmet Sci
2008; 30: 1–17.
3. Hwang ST, Janik JE, Jaffe ES, Wil-
son WH. Mycosis fungoides and
Sezary syndrome. Lancet 2008; 371:
945–957.
4. Diaconeasa A, Boda D, Neagu M,
Constantin C, Caruntu C, Vladau L,
Gutßu D. The role of confocal
microscopy in the dermato-oncol-
ogy practice. J Med Life 2011; 4:
63–74.
5. Koller S, Gerger A, Ahlgrimm-Siess
V, Weger W, Smolle J, Hofmann-
Wellenhof R. In vivo reflectance
confocal microscopy of ery-
thematosquamous skin diseases.
Exp Dermatol 2009; 18: 536–540.
6. Agero AL, Gill M, Ardigo M, Mys-
kowski P, Halpern AC, Gonzalez S.
In vivo reflectance confocal micros-
copy of mycosis fungoides: a preli-
minary study. J Am Acad Dermatol
2007; 57: 435–441.
Address:
Ai-E Xu
Department of Dermatology
Affiliated Hangzhou Clinical College
Anhui Medical University
Hangzhou 310009
China
Tel: +86 571 8782 7535
Fax: +86 571 8782 7535
e-mail: xuaiehz@msn.com

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