How dermatologic surgeons decide to proceed with surgery for nonmelanoma skin cancer when site identification is initially uncertain: A nationwide, multicenter, prospective study

BACKGROUND

Few studies show how dermatologic surgeons manage problems with site identification.

OBJECTIVE

To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question.

METHODS

Nationwide, prospective, multisite cohort study.

RESULTS

Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites.

LIMITATIONS

Sites were academic centers.

CONCLUSIONS

When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed.

Surface anatomy in dermatology: Part I-Clinical importance, diagnostic utility, and impact on medical management

This continuing medical education series reviews updated Delphi consensus surface anatomy terminology through the lens of common medical and procedural dermatology scenarios, helping to underscore high-yield points that can be readily integrated into clinical practice to support patient care. Part I of this series will discuss the current state of surface anatomy terminology in dermatology, outline implications of precise and consistent terminology, provide an illustrative overview of high-yield consensus terminology, highlight prominent landmarks that can aid in critical diagnoses, and relate the importance of precise terminology to medical management. Part II will draw upon consensus terminology to inform the management of cutaneous malignancies and support optimal outcomes in dermatologic procedures.

A practical guide to clinical photography prior to skin biopsy: key tips and proposed workflow

High-quality clinical photography has become an integral part of dermatology in the context of patient evaluation and monitoring, clinical teaching, and research. Technological advancements in smartphones have allowed dermatologists to incorporate photography in workflows; however, acquiring quality photos poses its own challenges. Outlining a best practice approach to image capture prior to biopsy will facilitate establishing a team-based approach for the implementation of clinical photography in workflow. We propose this guide with the intent of improving patient care though photography in the clinical setting and the goal of integrating high-quality photography into routine clinical practice.

Photographic Confirmation of Biopsy Sites Saves Lives

Quality photographic documentation of lesions prior to biopsy can decrease the risk of wrong site surgery, improve patient care, and save lives.

Preventing complications in dermatologic surgery: Presurgical concerns

Cutaneous surgery has become critical to comprehensive dermatologic care, and dermatologists must therefore be equipped to manage the risks associated with surgical procedures. Complications may occur at any point along the continuum of care, and therefore assessing, managing, and preventing risk from beginning to end becomes essential. This review focuses on preventing surgical complications pre- and postoperatively as well as during the surgical procedure.

Artificial Intelligence in Cutaneous Oncology

Skin cancer, previously known to be a common disease in Western countries, is becoming more common in Asian countries. Skin cancer differs from other carcinomas in that it is visible to our eyes. Although skin biopsy is essential for the diagnosis of skin cancer, decisions regarding whether or not to conduct a biopsy are made by an experienced dermatologist. From this perspective, it is easy to obtain and store photos using a smartphone, and artificial intelligence technologies developed to analyze these photos can represent a useful tool to complement the dermatologist's knowledge. In addition, the universal use of dermoscopy, which allows for non-invasive inspection of the upper dermal level of skin lesions with a usual 10-fold magnification, adds to the image storage and analysis techniques, foreshadowing breakthroughs in skin cancer diagnosis. Current problems include the inaccuracy of the available technology and resulting legal liabilities. This paper presents a comprehensive review of the clinical applications of artificial intelligence and a discussion on how it can be implemented in the field of cutaneous oncology.

Mohs Micrographic Surgery Pearls for the Nose and Lips

BACKGROUND

Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips can lead to larger defects and tumor recurrence, which can have aesthetic and functional repercussions for patients.

OBJECTIVE

To review pre-, intra-, and postoperative techniques and pearls for performing MMS on the nose and lips to optimize outcomes.

MATERIALS AND METHODS

Technical nuances and pearls cultured from the authors' own practice, those acquired from mentors and colleagues, and information identified from the literature are discussed to provide a logical approach to performing effective MMS on the nose and lips.

RESULTS

When performing MMS on the nose and lips, sound preoperative preparation, precise surgical technique, and particular attention to reducing false-positives and false-negatives while harvesting Mohs layers enhances the fidelity of the MMS procedure, minimizing defect sizes and reducing tumor recurrence.

CONCLUSION

Refining Mohs technique on the nose and lips allows more effective performance of tumor extirpation, improved microscopic evaluation, and more conservative reconstruction, leading to better patient outcomes.

Surgical site identification with personal digital device: A prospective pilot study

BACKGROUND

Various means to facilit ate accurate biopsy site identification have been proposed.

OBJECTIVE

To determine the accuracy of biopsy site identification by using photographs taken with a patient's digital device by a dermatologist versus professional medical photography.

METHODS

Photographs of circled biopsy sites were taken with personal digital devices by the principal investigator (PI). Another set of photographs was taken by a professional photographer. Secondary photographs were taken of the biopsy site location pointed to by the staff and PI on the basis of the personal digital device image and professional medical photography, respectively. On the basis of secondary photographs, 2 independent dermatologists determined whether the skin biopsy locations pointed out by the staff were consistent with the ones pointed out by PI.

RESULTS

Per dermatologist A, the staff correctly identified all 53 biopsy sites. Per dermatologist B, the staff were correct on 51 of 53 observations. Dermatologist C, the final arbiter, concurred with dermatologist A on the 2 cases in which dermatologist B was not certain of the location of the biopsy site.

LIMITATIONS

The mean interval from initial biopsy to reidentification of the site was 36.2 days.

CONCLUSION

Utilizing patients' personal digital devices is a cost-effective, Health Insurance Portability and Accountability Act-compliant, and readily available means to identify skin biopsy sites.

Do Bedside Visual Tools Improve Patient and Caregiver Satisfaction? A Systematic Review of the Literature

BACKGROUND

Although common, the impact of low-cost bedside visual tools, such as whiteboards, on patient care is unclear.

PURPOSE

To systematically review the literature and assess the influence of bedside visual tools on patient satisfaction.

DATA SOURCES

Medline, Embase, SCOPUS, Web of Science, CINAHL, and CENTRAL.

DATA EXTRACTION

Studies of adult or pediatric hospitalized patients reporting physician identification, understanding of provider roles, patient-provider communication, and satisfaction with care from the use of visual tools were included. Outcomes were categorized as positive, negative, or neutral based on survey responses for identification, communication, and satisfaction. Two reviewers screened studies, extracted data, and assessed the risk of study bias.

DATA SYNTHESIS

Sixteen studies met the inclusion criteria. Visual tools included whiteboards (n = 4), physician pictures (n = 7), whiteboard and picture (n = 1), electronic medical record-based patient portals (n = 3), and formatted notepads (n = 1). Tools improved patients' identification of providers (13/13 studies). The impact on understanding the providers' roles was largely positive (8/10 studies). Visual tools improved patient-provider communication (4/5 studies) and satisfaction (6/8 studies). In adults, satisfaction varied between positive with the use of whiteboards (2/5 studies) and neutral with pictures (1/5 studies). Satisfaction related to pictures in pediatric patients was either positive (1/3 studies) or neutral (1/3 studies). Differences in tool format (individual pictures vs handouts with pictures of all providers) and study design (randomized vs cohort) may explain variable outcomes.

CONCLUSION

The use of bedside visual tools appears to improve patient recognition of providers and patient-provider communication. Future studies that include better design and outcome assessment are necessary before widespread use can be recommended.

Traditional versus streamlined management of basal cell carcinoma (BCC): A cost analysis

BACKGROUND

Facing rising incidence of basal cell carcinoma (BCC) and increasing pressure to contain health care spending, physicians need to contemplate cost-effective paradigms for managing BCC.

OBJECTIVE

We sought to perform a cost analysis comparing the traditional BCC management scheme with a simplified detect-and-treat scheme that eliminates the biopsy before initiating definitive treatment.

METHODS

A decision analytic model was developed to compare the costs of traditional BCC management with the detect-and-treat scheme, under which qualifying lesions diagnosed clinically were either treated with shave removal or referred to Mohs micrographic surgery for on-site histologic check. Values for model parameters were based on literature and our institutional data analysis. Costs were based on 2014 Medicare fee schedule.

RESULTS

The average cost per lesion with detect-and-treat scheme was $449 for non-Mohs micrographic surgery-indicated lesions (vs $566 with traditional management, $117 in savings) and $819 for Mohs micrographic surgery-indicated lesions (vs $864 with traditional management, $45 in savings). The combined weighted average savings per case was $95 (15% of total average cost). Conclusions were similar under various plausible scenarios.

LIMITATIONS

Model parameter values may vary based on individual practices.

CONCLUSIONS

A simplified management strategy eliminating routine pretreatment biopsy can reduce BCC treatment cost without compromising quality of care.

[What's new in instrumental dermatology?]

This "What's new in instrumental dermatology" focuses on cutaneous oncologic surgery, base on a review of the 2012-2014 literature. First, the ability of dermatologists to make a good "oncologic reading of tumors" is the key of radical surgical treatment. Advantages and disadvantages of the biopsy are discussed. Then, the second message is the management of anticoagulants, that should not be interrupted for skin surgery. Despite recommendations, this practice is not followed in 40% of cases; this point is critical because bleeding complications are minor compared to potential morbidity of thrombotic events when stopping these medications. Regarding infection, nasal carriage of Staphylococcus aureus is identified as a risk factor for wound infection. A preoperative shower with chlorhexidine and mupirocin topical decolonization of nostril reduces this risk. Surgical techniques are trying to reach minimalism, by reducing undermining and scarring. On the trunk, using deep slow resorbable sutures improve scarring. In addition using adhesive sutures (strip) reduce the wideness of scar. On the face, the lower third of the nose is the most challenging because of the free edges, which are deformable. In this location bilobed or trilobed transposition flap offer the advantage of remaining in the nasal aesthetic unit and not disturbing the free edges of the nasal orifices. Regarding scarring, early hypertrophic scar is now well defined and linked with transposition flaps of the nasal region. An early treatment with intralesional corticosteroid injection appears to be effective. Finally, the biological mechanism of the effectiveness of compression in the prevention and treatment of dystrophic scar is now clear. The mechanotransduction explain how a mechanical stress of the skin activates biological cell pathways, which regulate the quality of collagen synthesis and the arrangement of skin fibrosis.

Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification

BACKGROUND

Determining the biopsy site location of a skin cancer before treatment is often challenging.

OBJECTIVE

To study the implementation and effectiveness of biopsy site selfies as a quality improvement measure for correct surgical site identification.

MATERIALS AND METHODS

In the first phase, the ability of dermatologic surgeon and patient to definitively identify the biopsy site and whether photography was needed to ensure site agreement were recorded. In the second phase, patients were requested to take biopsy site selfies, and after implementation, similar data were collected including whether a biopsy site selfie was helpful for definitive site identification.

RESULTS

In the first phase, the physician and patient were unable to identify the biopsy site 17.6% (49/278) and 25.5% (71/278) of cases, respectively. A photograph was needed in 22.7% of cases (63/278). After implementation of biopsy site selfies, the physician and patient were unable to identify the biopsy site 17.4% (23/132) and 15.2% (20/132) of cases, respectively. Biopsy site selfies were available for 64.1% of cases for which no internal image was available and critical for site identification in 21.4% of these cases.

CONCLUSION

Biopsy site selfies has proven to be helpful for correct surgical site identification by both the physician and the patient and may also provide further reassurance and confidence for patients.