Issues in the delivery of dermatologic surgery for skin cancer

Pediatric dermatologic surgery: our experience

BACKGROUND

Surgical treatment for pediatric skin disorders is used for diagnostic and therapeutic reasons. We underline these procedures are usually easy and uncomplicated without the need for general anesthesia. Objective of this study was to share our experience in the field of pediatric dermatologic surgery.

METHODS

We retrospectively analysed records of all pediatric patients receiving surgical therapy at the Dermatology Department of Spedali Civili of Brescia. Demographic data and treatments characteristics were recorded and analyzed.

RESULTS

During the study period of one year, 670 surgical treatments concerning pediatric patients were collected. Number of procedures progressively grows with increasing age. All treatments were performed under local anesthesia except for a dermatofibrosarcoma protuberans for which general anesthesia was needed.

CONCLUSIONS

Our data show that cryosurgery, electrodessication and excisional surgery constitute with equal proportion almost the whole of surgical procedures in dermatologic pediatric patients. Dermatologist's habit to perform surgery in local anesthesia avoids the risk of overtreatments, limits discomfort, anxiety, and pain perception linked to procedures performed.

Radiotherapy treatment for nonmelanoma skin cancer

Non-melanoma skin cancer is the most common malignancy in the USA, with an estimated 3.5 million cases per year. Treatment options include surgical excision, radiation therapy (RT), photodynamic therapy and topical agents. Although surgical excision remains the mainstay of therapy, RT offers an effective alternative. RT can be used as an adjunct to surgery in high-risk situations, or in cases where surgical excision would lead to impaired cosmesis and/or functional outcomes. Radiation treatment modalities for non-melanoma skin cancers are diverse. Studies in the literature have examined the clinical effects of a wide variety of modalities, areas of the body and dosages. The most common modalities include superficial or orthovoltage RT, electron beam therapy and high dose-rate brachytherapy. This article aims to review the diverse radiotherapy treatment modalities for non-melanoma skin cancers, focusing on tumor control and toxicity.

Dermatologic subspecialties in German inpatient dermatology:a national survey

BACKGROUND

In German-speaking countries, the specialty of dermatology is characterized by a large amount of subspecialties. Data providing information whether and to what extent these subspecialties are represented in German dermatology departments and clinics is not available.

METHODS

A national questionnaire survey was performed to determine the extent of involvement of dermatological subspecialties in dermatologic hospitals.Methods of descriptive statistics were applied.

RESULTS

Overall, 90 dermatologic departments participated in this survey with a response rate of 78.3 %.The subspecialties allergology, dermatooncology,and dermatologic surgery are represented in over 90 % of departments; the sub-specialties andrology, aesthetic dermatology, dermatopathology, microbiology,phlebology,photobiology,proctology, and wound healing are represented in over 50 % of clinics. Furthermore, the subspecialties allergology, dermato-oncology, photobiology, and dermatopathology have strong research or academic representation.

CONCLUSIONS

The present survey demonstrates that dermatologic subspecialties are widely represented in dermatologic departments and clinics not only by individuals with specialty training but also by those in higher academic posts. This demonstrated high expertise should be maintained in German dermatology and could be promoted by academic programs.

Derm Access: A New Triage System to Rapidly Identify Suspicious Skin Lesions

BACKGROUND

Many screening programs have been implemented for the general population; however, dermatology appointment wait times continue to be long. Changes in scheduling would allow patients with suspicious skin lesions access to more immediate care.

OBJECTIVES

The objective was to introduce a method for decreasing dermatology appointment wait times to allow patients with a high-risk skin lesion to be seen in a more efficient manner.

METHODS

A telephone screening method was developed to allow for the most suspicious lesions to be seen within 72 hours if the patient wished to do so; appointment time slots were left open in physician schedules to accommodate these patients; and wait time, procedure, and treatment data were collected and compared against national wait time data.

RESULTS

A total of 233 patients were seen during this study. A total of 146 of these patients were diagnosed with a cancerous or precancerous lesion. This was 63% of the total study population. The mean wait time in actual working days was 7.44 for this same period.

CONCLUSION

This program substantially decreased patient anxiety, increased patient satisfaction, increased public relations for the practice, and increased public awareness of skin cancer. The Derm Access strategy can be implemented in any practice to reduce wait times for suspicious skin lesions.

[Current situation of dermatologic surgery in Germany]

BACKGROUND

Dermatologic surgery has become an increasingly important issue in dermatology in recent years. At present, no current epidemiologic or care-related data on cutaneous surgery procedures in dermatology are available.

METHODS

To determine the extent of cutaneous surgery procedures in dermatological hospitals, a national survey was performed. Both the procedure codes for 2004 based on the OPS-classification and the DRG figures grouped to the major diagnostic category 09 of G-DRG version 2004 were considered in detail. Methods of descriptive statistics were applied.

RESULTS

The submitted data reveal that the contributing hospitals provided 164487 cutaneous surgery procedures in the investigation period. The vast majority is represented by extensive procedures and plastic-reconstructive operations, as opposed to less complex surgeries such as simple excisions. Analysis of DRG assignment indicates that surgical procedures account for 44.2% of inpatient cases.

CONCLUSIONS

The present survey demonstrates that in Germany cutaneous surgery procedures are widely performed by dermatological hospitals and dermatologists. The increasing incidence of melanoma and nonmelanoma skin cancer including precursor lesions will increase the need for dermatologists to perform cutaneous surgery in the future.

The Pitfalls of Treating All Actinic Keratoses as Squamous Cell Carcinomas

The greatest difficulties in managing a patient with numerous actinic keratoses is deciding the order in which to treat the specific lesions and what modality to use. The patient with a small number of lesions is probably most conveniently and cost effectively treated using destructive techniques like cryosurgery, electrodesiccation or photodynamic therapy with lasers. However, patients with large numbers of lesions are probably best managed using a topical chemotherapy agent, like 5-florouracil or imiquimod. If the patient's health insurance company limits coverage for the treatment of a specific number AK's per visit, it may be most prudent and logical to begin treatment of the largest or most rapidly growing AK's first and continue treatment of remaining lesions at subsequent visits until all lesions have been eradicated.

Documenting dermatology practice: ratio of cutaneous tumors biopsied that are malignant

BACKGROUND

Skin biopsy is an important part of dermatology practice. Little is known regarding dermatologist biopsying practices.

OBJECTIVE

The objective was to assess the ratio of malignant lesions biopsied in practice and factors that influence this ratio.

METHODS

Using a dermatopathology database, we analyzed tumors biopsied by dermatologists to determine the ratio of malignant to all tumors (malignancy ratio). Additional analyses were performed for factors influencing this ratio.

RESULTS

Over 6 months, 11,072 tumors were submitted. Overall, the malignancy ratio was 41.7%, 3.8% for pigmented lesions. Practice type, location, or use of dermatoscopy did not influence this ratio; provider age was positively correlated with a higher malignancy ratio (r=0.51; p=0.02) and was a predictor of malignancy ratio (b=0.02; p=0.04).

CONCLUSION

Approximately 40% of biopsied tumors were malignant. Dermatologists exhibit a wide range in their individual practice patterns. Increasing provider age predicted higher malignancy ratios with a 2% increase for each incremental year.

Diagnostic and Surgical Accuracy and Economic Aspects of Dermatological Surgery – A Pilot Study

BACKGROUND

Good skin care for oncological dermatological patients includes efficacious excision to achieve tumour control and economically reasonable costs. This field concerns dermatologists as much as other surgical specialities.

METHODS

Of 944 excisions and biopsies, we studied 114 epidermal carcinomas excised by plastic surgeons and dermatologists. This allowed us to compare the accuracy concerning oncological surgical aspects as well as the extrapolated costs produced by these two specialities.

RESULTS

Dermatologists are significantly more accurate concerning total excision of epidermal tumours compared to plastic surgeons.

CONCLUSION

From an economic point of view, plastic surgeons are increasingly more expensive than dermatologists. Most expenses are due to the use of a hospital operating room.

Mohs micrographic surgery of a papillary eccrine adenoma

BACKGROUND

Papillary eccrine adenoma (PEA) is a rare benign sweat gland neoplasm first described by Rulon and Helwig in 1977. Although these lesions typically behave in a benign fashion, PEA's on the volar surfaces may demonstrate more aggressive biologic behavior. Additionally, aggressive digital papillary adenomas (ADPA) may histologically simulate PEAs and behave in a more malignant fashion.

OBJECTIVE

To present a case report of a patient with an incompletely excised PEA that was successfully extirpated using Mohs micrographic surgery (MMS).

METHODS

A 51-year-old black woman was evaluated for the treatment of an incompletely excised PEA located on the dorsum of her left hand at the base of the thumb. Mohs micrographic surgery was felt to be the ideal treatment choice because of incomplete prior resections, ill-defined clinical borders, the need for conservative surgical excision to preserve sensory and motor function of the left hand, and the previously reported more aggressive nature of this tumor when located on volar surfaces. The patient underwent a two-stage, six section micrographically controlled excision using the fresh tissue technique.

RESULTS

Complete resection of the PEA without significant damage to neurovascular structures.

CONCLUSION

This case demonstrates the increasingly important role MMS is playing in the surgical management of a wide variety of cutaneous tumors. To our knowledge, this is the first time MMS has been used in the resection of a PEA.

[Clinicopathological correlation in 370 cases of skin minor surgery carried out by family physicians]

OBJECTIVE

To analyse the concordance between presurgical diagnosis and anatomical pathology diagnosis in 370 cutaneous lesions in primary care centres.

DESIGN

Descriptive study.Setting. Primary care centres and hospital pathology service, Medina del Campo.

MEASUREMENTS AND MAIN RESULTS

The prior diagnosis was compared with the anatomical pathology for simple agreement. There were 370 lesions. Complete date were obtained for 345 lesions of 298 patients (156 male and 142 female, aged between 6 and 98). Most problems diagnosed were nevocellular nevi (99 cases), fibroepithelial papiloma (72 cases), epidermoid cyst and viral wart (44). There was 63.1% global agreement between the laboratory report and doctor's diagnosis. Concordance and misdiagnosis were described in each type of lesion, mostly in skin cancer.

CONCLUSIONS

Performing minor surgery in primary care is feasible and effective. There is a high concordance between clinical diagnosis and anatomical pathology diagnosis.