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September 17, 2025Open Access

Diagnostic Accuracy of Ex Vivo Confocal Microscopy for Surgical Margin Assessment of High-Risk Nodular Basal Cell Carcinoma

WSWilliam StramkeUniversity of Lausanne LTLuca TonellottoUniversity of Lausanne EGEmmanuella GuenovaJohannes Kepler University of Linz

Key Points

EVCM achieved 93.8% sensitivity and 98.7% specificity for assessing surgical margins in high-risk nodular BCC, indicating strong diagnostic performance.
The positive predictive value was 88.2%, while the negative predictive value reached 99.4%, underscoring reliable margin assessments during surgery.
A retrospective monocentric study included 51 patients, where EVCM results were compared with traditional histology-based margin assessments.
Integrating EVCM into surgical workflows may enhance efficiency, yet further confirmatory studies in diverse clinical settings are necessary.

Abstract

Background: Accurate margin assessment during surgical treatment is essential to prevent recurrences of BCC. Mohs surgery or alternative peripheral and deep en-face margin assessment (PDEMA) based on conventional histopathology are considered the gold standard for excising high-risk BCC, as it allows stepwise and complete examination of peripheral and deep margins. However, it is labor-intensive and time-consuming. EVCM has emerged as a promising alternative, allowing rapid intraoperative evaluation of fresh excised tissue. Objective: To assess the diagnostic accuracy of EVCM in a PDEMA workflow of high-risk nodular BCCs. Methods: A retrospective monocentric study was conducted at the Lausanne University Hospital (CHUV) between March 2024 and May 2025. A total of 51 patients with histologically confirmed nodular BCCs considered as high-risk and thus addressed for EVCM-assisted excision were included, yielding 171 surgical margin samples. EVCM and conventional histology-based PDEMA analyses were compared. Results: EVCM achieved an overall sensitivity of 93.8% (95% CI: 71.7–98.9%) and specificity of 98.7% (95% CI: 95.2–99.7%) compared to conventional histology. The positive and negative predictive values were 88.2% (95% CI: 63.6–97.4%) and 99.4% (95% CI: 96.4–99.9%), respectively. Conclusion: EVCM demonstrates high diagnostic accuracy for the intraoperative PDEMA of high-risk, nodular BCC. Its integration in PDEMA surgical workflows may improve efficiency, although confirmatory studies are needed in broader clinical settings.

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