The Utility of Complete Skin Examinations

Background: Complete skin examinations (CSE’s), also known as full body skin examinations (FBSE’s), are routinely performed on new patients presenting to dermatology clinics with the goal of detecting pre-malignant and malignant cutaneous lesions, resulting in decreased morbidity and mortality. Current literature is limited, focusing solely on neoplasm detection. One recent retrospective study demonstrated the utility of FBSE’s in the early detection of melanoma in a private practice setting.(1) Data combining the discovery of incidental cutaneous neoplasms and premalignancies on CSE by a dermatologist is not readily available. Currently, groups such as the United States Preventive Forces Task Force do not make recommendations for CSE’s. The prognosis of cutaneous neoplasms is based on the depth of penetration, which can be curtailed if lesions are discovered early. Melanomas are most worrisome and the 5-year survival rate for those diagnosed with melanoma at a thickness of \u3c 0.76 mm is 98%. (2) Other malignancies include basal cell (BCC) and squamous cell carcinomas (SCC). Pre-malignancies include actinic keratoses (AK) and dysplastic nevi (DN). Although most dermatologists perform CSE’s on all new patients, many primary care physicians (PCP’s) do not regularly do so. Dermatologists are both more likely to perform CSE’s on patients perceived to be at high risk for cutaneous malignancy (3) and more likely than PCP’s to identify lesions. (4) Careful CSE’s result in cost and morbidity reduction. (4) Barriers to performing CSE’s include time limits and lack of emphasis on CSE’s during training. (3) While it seems appropriate for dermatologists and PCP’s to perform CSE’s in daily practice, PCP’s have a vital role in recognizing, diagnosing, and appropriately referring patients with concerning lesions. Objectives: Our pilot-study sought to provide data demonstrating the benefits of CSE’s for detecting both pre-malignant and malignant cutaneous lesions. By performing CSE’s on all new patients, we hoped to demonstrate that lesions that would otherwise go undiagnosed, are discovered earlier, decreasing morbidity. We hypothesized new patients presenting to the dermatology clinic for one skin lesion would actually have others discovered incidentally. Methods: Study subjects were identified as new patients presenting to the dermatology clinic at the University of Massachusetts Medical Center from September 2009 through March 2010, of varying ages, ethnicities, and sex. Each patient was asked to indicate “birthmarks, moles, or spots” they wanted examined; these lesions were considered the primary reason for the CSE. A CSE was performed on each subject with the patient’s complaints in mind. These were noted, and depending on the clinical diagnosis, the patient was biopsied, reassured, scheduled for follow-up, or treated. Other lesions detected by a dermatologist were noted, clinically diagnosed, and appropriately biopsied or treated, if necessary. Data analysis was done utilizing Microsoft excel. Data included the percentage of patients with physician-detected lesions and breakdown according to malignant potential and lack of it. Relationships between gender and incidental discovery of lesions were examined. Results: A total of 53 patients were recruited, 50 adults (94.3%) and 3 children (5.7%) from October 2009 through March 2010. There were 35 females (66.0%) and 18 males (34.0%). Of the 53 patients, a total of 10 (18.9%) had dermatologist-detected lesions and 5 (9.4%) had consequential (premalignant or malignant) lesions. There were not any lesions detected in children. A total of 14 lesions were detected and 8 (57.1%) of these lesions were considered consequential. Six (42.9%) of the 14 lesions were premalignant and 2 (14.3%) were malignant. Both malignancies were BCC’s and did not include more malignant neoplasms. Fifty percent of the premalignancies were diagnosed pathologically via a shave biopsy and 50 % were diagnosed clinically. All of the malignant lesions were diagnosed pathologically. Of the 35 females, 5 (14.3%) had lesions detected by a dermatologist. Of the 18 males, 5 (27.8%) had lesions detected similarly. There were no statistically significant differences in the patients having lesions discovered on exam with respect to gender (Fisher exact test p = 0.279); test of proportions revealed statistically insignificant results (p = 0.117, z score -1.188). An equal amount (50%) of premalignant lesions was discovered in both genders. Six (42.9%) of the 14 lesions were benign, including a blue nevus, nevus sebaceus, acne, dermatofibroma, and perioral dermatitis. Discussion: To our knowledge, our pilot-study is the first attempting to determine the utility of CSE’s in detecting lesions other than just cutaneous neoplasms. We also focused on premalignancies such as AK’s and DN. Because of our study, one female patient was worked up for neurofibromatosis type 1 (NF1) because she had multiple café-au-lait macules and inguinal freckling, suspicious for NF1. Our study’s limitations included the small patient population surveyed. The surveys were also not consistently used in all clinics. Although unintentional, this may have led to selection bias by not including new patients at all clinics attended by the dermatologists involved in the study. Our study also included twice as many females as males. Women may be more likely to seek dermatologic evaluation. Although no statistical significance was found with dermatologist detection of lesions comparing patient gender, this may have resulted from the small number of study subjects. Therefore, gender differences should be examined with a larger population. Racial and ethnic differences, as well as the cost-benefit ratio of discovering consequential lesions early on, should also be studied in the future. Conclusion: According to our pilot-study, we were able to demonstrate that a CSE does detect consequential lesions in 9.4% of patients. Although this is clinically significant, there does not appear to be any statistical significance since our population size was small. This pilot-study has been used as a basis for a larger scale study in the future with a larger patient population including children and adults of all ethnicities. Although further data collection is needed, this study demonstrates that lesions may be detected by a dermatologist even though a patient may not recognize them, helping decrease morbidity. References: 1. Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009;145(8):873-876. 2. Aitken, Joanne F, Youl, Philippa H, Janda, Monika, Lowe, John B, Ring, Ian T, Elwood, Mark. Increase in skin cancer screening during a community-based randomized intervention trial. Int J Cancer 2006;118:1010-1016. 3. Federman, Daniel G, Kravetz, Jeffrey D, Kirsner, Robert S. Skin cancer screening by dermatologists: prevalence and barriers. J Am Acad Dermatol 2002;46:710-4. 4. Hubert, Jason N, Callen, Jeffrey P, Kasteler, Scott J. Prevalence of Cutaneous Findings in Hospitalized Pediatric Patients. Pediatr Dermatol 1997;14(6):426-429. Presented as part of the Senior Scholars Program at the University of Massachusetts Medical School, May 3, 2010

Sentinel Lymph Node Biopsy Does Not Improve Disease-Specific Survival in Elderly Patients with Intermediate Thickness Melanoma

Objective: To determine whether sentinel lymph node biopsy (SLNB) is associated with improved disease-specific survival among elderly patients with intermediate-thickness melanoma Design: Retrospective cohort study of prospectively-maintained tumor registry Setting: Single institution tertiary care center. P atients: Adults ≥ 70 years of age, who underwent surgical intervention for melanoma from 2000-2013. Main Outcome Measures: The primary outcomes were overall survival (OS) and disease-free survival (DFS). Other clinicopathologic variables measured included age, gender, anatomic site, histologic type, tumor thickness, presence of adverse features, receipt and result of SLNB, and receipt of completion lymph node dissection (CLND). Results: Ninety-one patients (mean age 80 years, 54% male) underwent wide excision of an intermediate-thickness melanoma. Forty-nine patients (54%) received a SLNB. Seven of these biopsies (14%) were positive, and five patients (71%) went on to receive CLND. Five-year OS was 41% in patients who did not receive SLNB and 52% in patients who did receive SLNB (Fig. 1A). However, 5-year DFS was 79% in patients who did not receive SLNB and 77% in patients who did receive SLNB (Fig. 1B). Conclusions: Among elderly patients with intermediate-thickness melanoma, patients who received SLNB had higher 5-year OS than those who did not receive SLNB. However, the 5-year DFS is similar between the two groups, which suggests that the OS differences are related to non-melanoma factors. Routine SLNB for intermediate-thickness melanoma patients may not significantly change the outcome for this age group, and clinical decision-making should consider individual patient comorbidities and goals of care

Autoimmune Epilepsy: Some Epilepsy Patients Harbor Autoantibodies to Glutamate Receptors and dsDNA on both Sides of the Blood-brain Barrier, which may Kill Neurons and Decrease in Brain Fluids after Hemispherotomy

Purpose: Elucidating the potential contribution of specific autoantibodies (Ab's) to the etiology and/or pathology of some human epilepsies. Methods: Six epilepsy patients with Rasmussen's encephalitis (RE) and 71 patients with other epilepsies were tested for Ab's to the –B— peptide (amino acids 372-395) of the glutamate/AMPA subtype 3 receptor (GluR3B peptide), double-stranded DNA (dsDNA), and additional autoimmune disease-associated autoantigens, and for the ability of their serum and cerebrospinal-fluid (CSF) to kill neurons. Results: Elevated anti-GluR3B Ab's were found in serum and CSF of most RE patients, and in serum of 17/71 (24%) patients with other epilepsies. In two RE patients, anti-GluR3B Ab's decreased drastically in CSF following functional-hemispherotomy, in association with seizure cessation and neurological improvement. Serum and CSF of two RE patients, and serum of 12/71 (17%) patients with other epilepsies, contained elevated anti-dsDNA Ab's, the hallmark of systemic-lupus-erythematosus. The sera (but not the CSF) of some RE patients contained also clinically elevated levels of –classical— autoimmune Ab's to glutamic-acid-decarboxylase, cardiolipin, β2-glycoprotein-I and nuclear-antigens SS-A and RNP-70. Sera and CSF of some RE patients caused substantial death of hippocampal neurons. Conclusions: Some epilepsy patients harbor Ab's to GluR3 and dsDNA on both sides of the blood-brain barrier, and additional autoimmune Ab's only in serum. Since all these Ab's may be detrimental to the nervous system and/or peripheral organs, we recommend testing for their presence in epilepsy, and silencing their activity in Ab-positive patients

Dermatologic surgery and cosmetic procedures during pregnancy and the post-partum period

Dermatologic surgery is changed in the pregnant and postpartum patient. The physiologic changes associated with pregnancy require attention to the timing of surgery as well as the positioning and technique to maximize the outcome for the patient. The surgeon must also remember the risks to the fetus or nursing newborn in planning any surgical procedure. This is the one time when there is more than one patient in every procedure. This article will review the timing of surgery, tumors of pregnancy, surgical positioning, local anesthetics, surgical technique, and cosmetic procedures. This information should help provide a safe surgical procedure for the mother and the child

Shave removal plus electrodesiccation for the treatment of cutaneous neurofibromas

Cutaneous neurofibromas are a clinical feature of both neurofibromatosis type I and neurofibromatosis type II. Neurofibromas are discrete masses that arise from peripheral nerves and are composed of Schwann cells, mast cells, fibroblasts, and perineural cells. Current treatment of neurofibromas consists primarily of standard surgical excision or laser therapy. A removal technique that is time efficient, cost effective, and poses little discomfort or functional impairment for the patient is desirable. The authors describe the technique of shave removal with electrodesiccation for multiple neurofibromas

Avoiding Medical Errors in Cutaneous Site Identification: A Best Practices Review

BACKGROUND: Although the field of dermatology has a relatively low incidence of medical errors, dermatologic surgery is a major area where medical errors occur. OBJECTIVE: The purpose of this article is to catalog the many cutaneous site identification techniques used by practitioners and determine which techniques are most evidence based. MATERIALS AND METHODS: A comprehensive literature review of cutaneous surgical site identification techniques and medical errors in dermatology. RESULTS: Wrong-site surgery often occurs because of an inability to identify the surgical site because of factors such as inadequate documentation from referring physicians, well-healed scars obscuring the biopsy site, and a patient\u27s inability to visualize the surgical site. Practitioners use techniques such as photography, dermabrasion, written descriptions using anatomic landmarks, and site identification protocols for surgical site identification. CONCLUSION: Site identification remains a challenge for dermatologists and is a leading cause of medical errors in this field. Patients are often unreliable in their ability to identify biopsy sites; therefore, practitioners must take a proactive role to ensure that medical errors do not occur. This article provides a thorough description and evaluation of current site identification techniques used in dermatology with the aim to improve quality of care and reduce medical errors

Single-Cell Squamous Carcinoma: An Underreported High-Risk Variant

BACKGROUND: There is increasing interest in establishing diagnostic and treatment guidelines for high-risk squamous cell carcinoma (SCC). Single-cell SCC has been recognized as a high-risk subtype but continues to be a less commonly reported and more poorly understood variant. OBJECTIVE: To present the current literature on single-cell SCC. MATERIALS AND METHODS: A review of the literature on single-cell squamous cell carcinoma. RESULTS: There are fewer than 100 cases of single-cell SCC in the literature. The reporting studies demonstrate an increase in the risk of metastasis compared with non-single-cell tumors. Confounding variables reported include other coexisting high-risk features: diameter \u3e 2 cm, depth \u3e 6 mm, and difficulty detecting single tumor cells. It is therefore unclear whether single-cell SCC is an independent risk factor for recurrence and regional spread. Studies have described use of immunostaining as a means to improve tumor detection. CONCLUSION: Single-cell SCC continues to be an underreported SCC variant. Given its apparent aggressive behavior, more studies are warranted to better understand its tumor biology and behavior and to improve patient outcomes. Based on our present knowledge, complete tumor excision with or without the aid of immunostaining and use of multidisciplinary care are recommended